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272 Laboratory Medicine in Psychiatry and Behavioral Science
Urine bilirubin
Type of test Component of routine urinalysis
Background and explanation
of test
The presence of even trace amounts of bilirubin in the urine
is not normal and should be investigated. Any disease pro
-
cess that results in increased conjugated bilirubin in the cir-
culation can increase the level of bilirubin in urine.
In the absence of disease, conjugated bilirubin is excreted
through the GI tract. With hepatobiliary disease, it enters
the circulation instead and is filtered and excreted by the
kidneys. Urine bilirubin provides an early warning of hepa-
tocellular disease or biliary obstruction (intrahepatic or ex-
trahepatic). Bilirubin can appear in the urine before jaundice
appears. In addition, the presence or absence of urinary bil
-
irubin can help in determining the etiology of jaundice;
urine bilirubin is absent in hemolytic disease.
Relevance to psychiatry and
behavioral science
Urine bilirubin can be present in patients with hepatitis, cir-
rhosis, or (more rarely) hyperthyroidism. It may be useful in
monitoring patients who are in treatment for drug/alcohol
dependence. Several herbal remedies used by behavioral
health patients can cause bilirubinuria, including kava
kava, germander, and chaparral.
Preparation of patient See Urinalysis.
Indications •
Component of routine urinalysis
• Early diagnosis of hepatobiliary disease
• Monitoring treatment for hepatitis
Reference range Negative (<0.02 mg/dL)
Critical value(s) None
Increased levels • Hepatitis, cirrhosis, and other liver diseases
• Obstructive biliary tract disease
• Malignancy (liver or biliary tract)
• Sepsis
• Hyperthyroidism
• Herbal medicines (kava kava, germander, chaparral)
Decreased levels Not applicable
Interfering factors Urine left standing causes false-negative results.
Decreased sensitivity of the test is seen with the use of high
doses of vitamin C or nitrates.
Phenazopyridine (Pyridium)-like drugs or urochromes can
turn urine amber or red and mask bilirubin reaction.
Cross-references Bilirubin
Cirrhosis
Hepatitis, Viral
Urinalysis
https://t.me/med1917
273 Laboratory Tests
Urine bilirubin (continued)
American Association for Clinical Chemistry: Lab Tests Online. Available at: https://www.testing.com.
Accessed October 2021.
Dasgupta A, Bernard DW: Herbal remedies: effects on clinical laboratory tests.Arch Pathol Lab Med
130(4):521–528, 2006
Fischbach FT, Fischbach MA: A Manual of Laboratory and Diagnostic Tests, 10th Edition. Philadelphia,
PA, Wolters Kluwer Health/Lippincott Williams and Wilkins, 2018
Simerville JA, Maxted WC, Pahira JJ: Urinalysis: a comprehensive review. Am Fam Physician 71:1153–
1162, 2005
https://t.me/med1917
274 Laboratory Medicine in Psychiatry and Behavioral Science
Urine blood, hemoglobin, and myoglobin
Type of test Component of routine urinalysis
Background and explanation
of test
This part of the urinalysis detects RBCs, hemoglobin, and
myoglobin.
• Hematuria is present when intact RBCs are identified and
indicates disease or trauma to the kidney or other part
of the genitourinary system.
• Hemoglobinuria is present when free hemoglobin is iden-
tified; this indicates either intravascular hemolysis that
exceeds the capacity to metabolize or store excess free
hemoglobin or lysis of RBCs in the urinary tract itself.
• Myoglobinuria is present when the urine is positive for
occult blood, but no RBCs are identified; this indicates
injury to muscle tissue, with the excretion of muscle pro-
tein into the urine. Urine containing myoglobin can ap-
pear highly colored.
Relevance to psychiatry and
behavioral science
Heavy smoking is associated with hematuria. NMS and ECT
are known to cause myoglobinuria along with significantly
elevated creatine kinase levels. Rhabdomyolysis with myo
-
globinuria is associated with succinylcholine, halogenated
anesthetics, propofol, and corticosteroids.
Preparation of patient See
Urinalysis.
Females should note whether they are menstruating at the
time of sampling.
Indications Component of routine urinalysis
Reference range Negative (<10 erythrocytes/μL or <0.03 mg free hemoglo-
bin/dL)
Critical value(s) Blood in urine is not a normal finding. A positive test for blood
should be confirmed on a second urine specimen. If the test
is still positive, the cause should be investigated.
Increased levels Intact RBCs (hematuria)
Acute cystitis, lupus nephritis, kidney or genitourinary can-
cer, kidney or urinary tract stones, malignant hypertension,
glomerulonephritis, pyelonephritis, trauma, polycystic kid
-
ney disease, leukemia, thrombocytopenia, strenuous exer-
cise, benign recurrent (familial) hematuria, heavy smoking,
drugs (nephrotoxins such as amphotericin, anticoagulants
such as warfarin, hemolytic drugs such as aspirin)
Free hemoglobin (hemoglobinuria)
Extensive burns, bleeding after prostate surgery, transfusion
of incompatible blood, malaria, certain poisons, hemolytic
disorders (sickle cell anemia, thalassemia), kidney infarc-
tion, fava bean sensitivity, disseminated intravascular coag-
ulation, strenuous exercise, paroxysmal hemoglobinuria, or
hypotonic alkaline urine
https://t.me/med1917
275 Laboratory Tests
Urine blood, hemoglobin, and myoglobin (continued)
Increased levels (continued) Myoglobinuria
NMS, ECT, trauma, intense physical activity, muscular dys-
trophy, malignant hyperthermia
Decreased levels Not applicable
Interfering factors Sensitivity of the test is reduced by high urine specific grav-
ity or elevated urine protein.
Menstrual blood or blood from urinary catheter trauma may
contaminate the specimen.
Bleach used to clean urine containers may cause false-
positive results.
Drugs causing false-positive results include bromides,
copper, iodides, and oxidizing agents.
High-dose vitamin C intake may cause false-negative
results.
Cross-references Neuroleptic Malignant Syndrome
Urinalysis
Urinary Tract Infection
Urine Red Blood Cells (RBCs) and RBC Casts
American Association for Clinical Chemistry: Testing.com. Available at: https://www.testing.com. Ac-
cessed October 2021.
Angelini C, Marozzo R, Pegoraro V, Sacconi S: Diagnostic challenges in metabolic myopathies.Expert
Rev Neurother 20(12):1287–1298, 2020
Barrons RW, Nguyen LT: Succinylcholine-induced rhabdomyolysis in adults: case report and review of
the literature.J Pharm Pract 33(1):102–107, 2020
Cabral BMI, Edding SN, Portocarrero JP, Lerma EV: Rhabdomyolysis.Dis Mon 66(8):101015, 2020
Fischbach FT, Fischbach MA: A Manual of Laboratory and Diagnostic Tests, 10th Edition. Philadelphia,
PA, Wolters Kluwer Health/Lippincott Williams and Wilkins, 2018
Laoutidis ZG, Kioulos KT: Antipsychotic-induced elevation of creatine kinase: a systematic review of the
literature and recommendations for the clinical practice.Psychopharmacology (Berl) 231(22):4255–
4270, 2014
Simerville JA, Maxted WC, Pahira JJ: Urinalysis: a comprehensive review. Am Fam Physician 71:1153–
1162, 2005
https://t.me/med1917
276 Laboratory Medicine in Psychiatry and Behavioral Science
Urine casts
Type of test Component of routine urinalysis
Background and explanation
of test
Casts are tube-shaped particles sometimes found in urine
that are formed from coagulated proteins released in the
distal convoluted tubule or collecting duct of the nephron.
In the absence of pathology, only hyaline casts are seen.
These are clear and few in number, although the number can
increase with strenuous exercise. Other types of casts in-
clude cellular casts of WBCs or RBCs, granular casts, fatty
casts, and waxy casts. Some types have specific pathological
significance, as noted in the Abnormal Test section below. In
general, low-flow, high-salt, and low-pH conditions in the
nephron favor cast formation. To visualize casts, the urine
sample is centrifuged, and a drop of the sediment is exam
-
ined under low power. Phase-contrast microscopy is supe-
rior to bright field microscopy for this purpose.
Relevance to psychiatry and
behavioral science
The synthetic cannabinoid commonly known as “spice” has
been known to cause kidney injury in the form of acute tu
-
bular necrosis or acute interstitial nephritis, with granular
casts formed. In COVID-19 infection, urinalysis findings
have included myoglobin casts and cellular debris casts.
Preparation of patient See Urinalysis.
Indications Component of microscopic analysis of urine sediment in-
cluded in complete urinalysis
Reference range Broad, waxy casts: 0
Fatty casts: 0
Granular casts: 0–2
Hyaline casts: 0–2
RBC casts: 0
WBC casts: 0
Renal tubular epithelial casts: 0
Critical value(s) None
Abnormal test • Broad, waxy casts seen in urinary stasis, which occurs in
renal failure.
• Fatty casts indicate lipids in urine, usually in association
with nephrotic syndrome.
• Granular casts are a nonspecific sign of kidney disease.
• Hyaline casts are caused by dehydration, exercise, or di-
uretic medication and are usually benign.
• RBC casts indicate bleeding into the kidney tubule asso-
ciated with glomerular disease, as found in SLE.
• WBC casts indicate infection of the renal parenchyma,
the most common cause being pyelonephritis.
• Renal tubular epithelial casts indicate tubule injury as-
sociated with renal tubular necrosis, viral disease, or
transplant rejection.
https://t.me/med1917
277 Laboratory Tests
Urine casts (continued)
Interfering factors Casts dissolve readily in alkaline or dilute urine. RBC casts
may appear in urine after strenuous physical activity.
Cross-references Urinalysis
American Association for Clinical Chemistry: Testing.com. Available at: https://www.testing.com. Ac-
cessed October 2021.
Fischbach FT, Fischbach MA: A Manual of Laboratory and Diagnostic Tests, 10th Edition. Philadelphia,
PA, Wolters Kluwer Health/Lippincott Williams and Wilkins, 2018
Fogazzi GB, Delanghe J: Microscopic examination of urine sediment: phase contrast versus bright
field.Clin Chim Acta 487:168–173, 2018
Simerville JA, Maxted WC, Pahira JJ: Urinalysis: a comprehensive review. Am Fam Physician 71:1153–
1162, 2005
Zarifi C, Vyas S: Spice-y Kidney failure: a case report and systematic review of acute kidney injury attrib-
utable to the use of synthetic cannabis. Perm J 21:16–160, 2017
https://t.me/med1917
278 Laboratory Medicine in Psychiatry and Behavioral Science
Urine color
Type of test Component of routine urinalysis
Background and explanation The color of normal urine comes from the pigment uro-
of test chrome, a product of metabolism. The color can change with
the use of certain drugs, ingestion of highly colored foods,
and a limited number of diseases.
Relevance to psychiatry and
behavioral science
Urine color may be a focus of concern for some somatizing
patients. A limited group of psychotropic medications
causes discoloration of the urine. Diseases causing urine dis
-
coloration include hepatitis, in which darkening of the urine
is seen; acute intermittent porphyria, in which urine darkens
on exposure to light; and Addison’s disease. Other factors
affecting urine color that may be of particular interest to psy
-
chiatrists and behavioral medicine clinicians are listed in the
Abnormal Findings section below.
Preparation of patient See Urinalysis.
Indications See Urinalysis.
Reference range Normally, urine is pale yellow to amber, depending on the
patient’s state of hydration. Straw-colored urine indicates
low specific gravity. Amber urine indicates high specific
gravity, usually with low urine output.
Critical findings Red urine should be checked for hemoglobin; if present, the
patient should be questioned about recent trauma, infection,
or vigorous exercise. If occult blood is not present in red
urine, the patient should be evaluated for porphyria. Other
urine colors should be investigated using appropriate tests.
Abnormal findings • Colorless urine (suggests high urine output): large fluid in-
take, as with polydipsia; untreated diabetes with glycos-
uria; diabetes insipidus; excessive alcohol ingestion;
diuretic therapy; or anxiety
• Dark yellow to amber urine: bilirubin; urobilinogen; use of
chlorpromazine, nitrofurantoin, or riboflavin; excessive
ingestion of carrots or use of herbal remedies, such as
cascara sagrada
• Orange urine: concentrated urine as with dehydration;
bile pigment; excessive ingestion of vitamin Aor carrots;
medications such as nitrofurantoin, used for urinary
tract infection; use of phenothiazines, rifampin, heparin,
or warfarin
• Green urine: Pseudomonas infection; ingestion of chloro-
phyll, biliverdin, or certain vitamins or diuretics
• Red urine: RBCs, hemoglobin, myoglobin, methemoglo-
bin, oxyhemoglobin, porphyrins, malaria, or ingestion
of beets, rhubarb, or senna (see also Critical Findings sec-
tion above)
• Brown urine: Addison’s disease; presence of bile, myo-
globin; use of levodopa, metronidazole, nitrofurantoin,
or sulfonamides
https://t.me/med1917
279 Laboratory Tests
Urine color (continued)
Abnormal findings
(continued)
• Black urine: iron, melanin, methemoglobin, urobilinogen,
or use of levodopa, chloroquine, metronidazole, senna,
or herbal remedies such as cascara sagrada
• Blue urine: use of amitriptyline, methylene blue, triam-
terene, or nitrofurantoin; Pseudomonas infection
• Milky urine: cystinuria, presence of fat or abundant
WBCs or phosphates
Interfering factors Normal urine begins to darken on standing within
30 minutes.
Cross-references Urinalysis
American Association for Clinical Chemistry: Testing.com. Available at: https://www.testing.com. Ac-
cessed October 2021.
Fischbach FT, Fischbach MA: A Manual of Laboratory and Diagnostic Tests, 10th Edition. Philadelphia,
PA, Wolters Kluwer Health/Lippincott Williams and Wilkins, 2018
Simerville JA, Maxted WC, Pahira JJ: Urinalysis: a comprehensive review. Am Fam Physician 71:1153–
1162, 2005
https://t.me/med1917
280 Laboratory Medicine in Psychiatry and Behavioral Science
Urine crystals
Type of test Component of routine urinalysis
Background and explanation
of test
Crystals are a normal component of the urine that form
when minerals are present in sufficient concentration, with
urine protein often acting as a nidus for crystal formation.
Different types of crystals are formed at different pH levels.
Small numbers of magnesium ammonium phosphate crys
-
tals (struvite) are not harmful, but other types of crystals can
be toxic and/or indicate the presence of systemic disease, as
noted in the Positive Test section below. Dehydration as well
as high-protein, high-salt diets can promote crystal forma
-
tion. Aggregation of crystals can create kidney and lower
urinary tract stones and may lead to hydronephrosis, pyelo
-
nephritis, or acute renal failure.
Relevance to psychiatry and
behavioral science
Ethylene glycol poisoning is associated with calcium oxa-
late crystals. Commonly used medications (e.g., ampicillin
and sulfonamides) and radiographic dyes can form crystals
in the presence of dehydration.
Preparation of patient Patients should not fast before testing but should continue
their usual diet and hydration regimen. If crystals found on
routine urinalysis are to be investigated further, a 24-hour
urine sample should be requested.
Indications Component of routine urinalysis as well as more detailed
investigations with 24-hour urine sample
Reference range The following crystals are considered normal or of no clinical
significance:
• Acid urine: amorphous urates, sodium urate
• Alkaline urine: amorphous phosphates, calcium carbon-
ate, and calcium phosphate
Ammonium biurate crystals may be normal but require a
second urine sample to confirm.
Critical value(s) None
Positive test • Acid urine: bilirubin crystals with elevated bilirubin lev-
els; uric acid crystals with gout, increased purine metab-
olism, or Lesch-Nyhan syndrome
• Acid, neutral, or mildly alkaline urine: calcium oxalate—
may be normal, but large amounts in freshly voided
specimen may suggest renal disease, liver disease, dia-
betes mellitus, ethylene glycol poisoning, or excessive
doses of vitamin C
• Alkaline, neutral, or mildly acidic urine: triple phosphate
(struvite)—may be normal or may indicate urinary sta-
sis with chronic cystitis, chronic pyelitis, or enlarged
prostate
Negative test None
Interfering factors Urine must be examined immediately; urine left standing at
room temperature yields invalid results.
Cross-references Urinalysis
https://t.me/med1917
281 Laboratory Tests
Urine crystals (continued)
American Association for Clinical Chemistry: Testing.com. Available at: https://www.testing.com. Ac-
cessed October 2021.
Cohen SM: Crystalluria and chronic kidney disease.Toxicol Pathol 46(8):949–955, 2018
Fischbach FT, Fischbach MA: A Manual of Laboratory and Diagnostic Tests, 10th Edition. Philadelphia,
PA, Wolters Kluwer Health/Lippincott Williams and Wilkins, 2018
Rimer JD, Kolbach-Mandel AM, Ward MD, Wesson JA: The role of macromolecules in the formation of
kidney stones. Urolithiasis 5(1):57–74, 2017
Simerville JA, Maxted WC, Pahira JJ: Urinalysis: a comprehensive review. Am Fam Physician 71:1153–
1162, 2005
Williams JC Jr, Gambaro G, Rodgers A, et al: Urine and stone analysis for the investigation of the renal
stone former: a consensus conference.Urolithiasis 49(1):1–16, 2021
https://t.me/med1917
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