Topnotch Lab Interpretation For Moonlighters

Laboratory Interpretation  
Made Easy
Diana Tamondong-Lachica, MD, FPCP

OUTLINE
● Urinalysis
● Renal Function Tests
● Complete Blood Count
EXERCISES
25 y/o, female patient with Urinalysis result showing:

Protein = +++
RBC = 15 – 20 / hpf
WBC = 10 – 15 / hpf
Which part of the kidney is most likely injured ?

A. Glomerular area
B. Tubulo-interstitial area
C. Vascular area
50 y/o, male, with recent treatment for Herpes Zoster,
No genitourinary symptoms, had urinalysis result of:
Specific Gravity = 1.010
Protein = trace
Glucose = +1
RBC = 0 - 2 / hpf
WBC = 25 – 30 / hpf
Urine C/S = negative
The patient most likely has:

A. Urinary tract infection
B. Glomerulonephritis
C. Tubulo-Interstitial nephritis
sCr 120 µmol/L 120 µmol/L
Question:
Both of them have equivalent renal function
True
False
Given a 70 y/o, male, diabetic patient,
with body wt = 72 kg
Serum Creatinine of 1 mg/dl
What is the Creatinine Clearance of the patient ?

A. CrCl of 100 ml/min
B. CrCl of 70 ml/min
C. CrCl of 50 ml/min
To which Stage of Chronic Kidney Disease

should the patient be classified ?
A. CKD Stage 1
B. CKD Stage 2
C. CKD Stage 3
INFORMATION THAT CAN BE
OBTAINED BY SIMPLE URINALYSIS
Appearance
Specific gravity
Chemical tests
pH, Protein, Glucose, Ketones,
Blood, Urobilinogen, Bilirubin,
Nitrites, Leukocyte esterase
Cells
Casts
Crystals
URINE COLOR CAUSES
Faint yellow Normal
White Pus, Chyle, Phosphate crystals
Pink / red / brown Red blood cells, Hemoglobin,

( tea colored ) Myoglobin, Beets, Senna,
Methyldopa, Metronidazole,
Food coloring
Yellow / Orange Bilirubin, B complex, Rifampicin,

Iron, Nitrofurantoin, Phenytoin
Brown / black Methemoglobin, melanin
Blue / green Pseudomonas, Dye, Chlorophyll

PHYSICAL CHARACTERISTICS
Normal Clinical Value

Values
Specific 1.003 – 1.030 1.000-1.005 Diabetes insipidus
gravity
>1.030 Dehydration, contrast
dyes, glucose,
mannitol
Turbidity Clear Infection, crystals.

Chyluria (milky white)
CHEMICAL CHARACTERISTICS
Normal values Comments

Urine pH 4.5 - 6 Alkaline urine - vegetarian diet,
UTI, Renal Tubular Acidosis
Acidic urine – uric acid crystals
Urine negative Regular Dipsticks detects only

protein (Total protein albumin> 300 mg / L
<150mg/24hrs)
(Albumin <30mg/
24hrs)
WAYS TO QUANTIFY PROTEINURIA
24 hr urine collection – cumbersome, prone to

collection error
Albumin / creatinine ratio is a simple and accurate

method of quantifying proteinuria
Ex. A/C ratio of 200 mg protein/Gm crea equivalent
to urine protein of 200mg/24h
Urine Electrophoresis – to determine type of protein

MICROALBUMINURIA
• Marker of silent DM nephropathy
• Significant predictor or overt nephropathy
• First manifestation of injury to the

glomerular filtration barrier
TYPES OF PROTEINURIA 
• ORTHOSTATIC or POSTURAL
• FUNCTIONAL
- High fever, exercise, heat stroke, CHF
• GLOMERULAR
• TUBULAR
• OVERFLOW
- Hyperglobulinemic states
URINE MICROSCOPY
Crystals
Urates, calcium, oxalate, triple
phosphates, cystine, drugs
Cells Red blood cells, white blood cells,

tubular cells, fat bodies, squamous
cells
Casts
Hyaline, granular, RBC, WBC, broad,
waxy
Organisms Bacteria, yeasts, trichomonas

Miscellaneous Spermatozoa, mucus treads
URINE MICROSCOPY
CELLS AND CASTS NORMAL PATHOLOGY
Leucocytes 1-4 /HPF UTI, interstitial nephritis
Erythrocytes 0-2 /HPF Stones, obstruction, UTI,

glomerular
Tubular cells FEW Renal failure
Hyaline casts FEW Dehydration
Course granular NONE CKD

casts
Muddy brown cast NONE Acute tubular necrosis
WBC casts NONE Pyelonephritis
RBC cast NONE Glomerulonephritis

HEMATURIA
May originate anywhere from the glomerulus to the

urethral meatus
Normal: RBC in the urine is between 0 – 2 / HPF
Abnormal: > 3 RBC / HPF
Shape of RBC is important:

Normal shape RBC – originate from collecting system
Dysmorphic RBC - originate from glomerulus
CAUSES OF HEMATURIA AND
URINALYSIS FINDINGS
Hematuria with Proteinuria , RBC Glomerular pathology

casts
Hematuria coincident with URTI, IgA nephropathy

occasional proteinuria
Hematuria days or weeks after Acute post-streptococcal

URTI glomerulonephritis
Hematuria with Pyuria UTI, Glomerulonephritis
Hematuria, Crystals Stone disease

OTHER CELLS
Eosinophils – seen in allergic interstitial nephritis,

atheroembolism
Epithelial cells
squamous cells – contaminant
transitional cells – from pelvis to urethral lining
renal tubular cells - large amount seen in ATN
OTHER CAUSES OF PYURIA
Contamination during collection
Vaginal secretions
Foreskin secretions
Non-infectious causes
VesicoUreteral Reflux Hypercalcemic nephropathy
Analgesic Nephropathy Lithium toxicity
Uric acid nephropathy Hyperoxalosis
Polycystic kidney Heavy metal toxicity
ATN Carcinoma of Urinary tract
Transplant rejection Renal calculi
Allergic interstitial nephritis Sickle cell disease
Sarcoidosis Idiopathic interstitial cystitis
Radiation nephritis Glomerulonephritis
Infectious diseases
TB, chlamydial / gonococcal urethritis, Leptospirosis, Viral cystitis
Infections adjacent to urinary tract
Appendicitis, diverticulitis
CLINICAL SYNDROMES OF
RENAL DISEASE
SITE OF INJURY URINALYSIS EXAMPLES
FINDINGS
GLOMERULUS Hematuria (dysmorphic) Nephritic syndrome
Pyuria Nephrotic syndrome
Proteinuria IgA nephropathy
Cells, casts
TUBULES Abnormal urine specific Urinary tract infection

INTERSTITIUM gravity, pH Urinary tract obstruction
Proteinuria Renal tubular acidosis
Hyaline casts (RTA)
Hematuria, pyuria
VASCULAR Bland sediments Hypertension

(no cells, hyaline casts
Differentiation between nephrotic and nephritic
syndromes
Features Nephrotic Nephritic

ONSET insidious abrupt
EDEMA ++++ ++
BP normal raised
JVP norma/low raised
PROTEINURIA ++++ ++
HEMATURIA may/may not occur +++
RBC CASTS absent Present
ALBUMIN low Normal/sl. decreased

Serum Creatinine
● Mainly derived from metabolism of creatine/creatine

phosphokinase from skeletal muscle cells
● Produced in almost constant rate
● Steady state concentration dependent on renal

excretion w/c mainly reflects of GFR
Cockcroft-Gault Formula*
(140 – Age ) X Wt in kgs

______________________
72 X Cr in mg/dl
*Multiply result by 0.85 for female
CrCl normal values = 90 – 120 ml/min

Normal decline rate 1 ml/min/yr after age 40
SERUM CREATININE ALONE IS NOT A GOOD

INDICATOR OF ESTIMATED GFR
Creatinine Clearance
● Widely used method to estimate GFR
● CrCl = (Ucr)(V) / Pcr

(Timed urine collection)
● Quick estimation of creatinine clearance use

Cockcroft-Gault formula and MDRD formula
Factors that can affect BUN levels
Increase levels – high protein intake, hyperalimentation
GI bleeding, Catabolic states, Steroids
Tetracyclines, volume depletion
Decrease levels – liver disease, pregnancy
BUN to Creatinine ratio

Normal = 10 – 20 : 1
Volume depletion ( Prerenal ) = > 20 : 1
Factors Affecting Markers of  
Kidney Function
RIFLE classification of  
Acute Kidney Injury
UO < 0.3 ml/kg/h x24h or
Outcome
Differentiating Acute vs
Chronic Renal Failure
Points favoring CRF:
1) History
Prior history of DM, HPN, Renal or GU disease
Review of old medical records
Onset of nocturia
2) PE
Pallor, Skin changes
3) Lab
Severe anemia, elevated PTH and phosphorus,
low serum calcium
4) Radiology
Bilateral small kidneys, osteodystrophy (bone changes)
Note: Acute injury on top of chronic kidney is common

POST - TEST:
25 y/o, female patient with Urinalysis result showing:

Protein = +++
RBC = 15 – 20 / hpf
WBC = 10 – 15 / hpf
Which part of the kidney is most likely injured ?

A. Glomerular area
B. Tubulo-interstitial area
C. Vascular area
50 y/o, male, with recent treatment for Herpes Zoster,
No genitourinary symptoms, had urinalysis result of:
Specific Gravity = 1.010
Protein = trace
Glucose = +1
RBC = 0 - 2 / hpf
WBC = 25 – 30 / hpf
Urine C/S = negative
The patient most likely has:

A. Urinary tract infection
B. Glomerulonephritis
C. Tubulo-Interstitial nephritis
sCr 120 µmol/L 120 µmol/L
Question:
Both of them have equivalent renal function
True
False
Given a 70 y/o, male, diabetic patient,
with body wt = 72 kg
Serum Creatinine of 1 mg/dl
What is the Creatinine Clearance of the patient ?

A. CrCl of 100 ml/min
B. CrCl of 70 ml/min
C. CrCl of 50 ml/min
To which Stage of Chronic Kidney Disease

should the patient be classified ?
A. CKD Stage 1
B. CKD Stage 2
C. CKD Stage 3
Complete Blood Count
PARAMETER NORMAL REMARKS
VALUES
Hemoglobin M: 133 - 162 g/L Consider transfusion if with acute
F: 120 - 158 g/L blood loss, symptomatic chronic
anemia
Caution with hemolysis
Hematocrit M: 0.38 - 0.46
F: 0.35 - 0.44
Mean corpuscular 79-93.3 fL Decreased in iron deficiency,
volume (MCV) thalassemia
Increased in megaloblastic anemia,
structural hemoglobinopathies
Mean corpuscular 26.7 - 31.9 pg Same as MCV
hemoglobin (MCH)
Mean corpuscular 323-359 g/L Increased in hereditary spherocytosis

hemoglobin
concentration (MCHC)
Complete Blood Count
White blood 4.0-11.0 x 109/L Increased in leukemia/

cell count leukemoid reaction
Platelet count 150-450 x 109/L Increased in iron deficiency,

CML
Reticulocyte 0.8-2.3% Increased in hemolysis
count/ < 14.5% Decreased in bone marrow
Red cell failure states
distribution
width (RDW)
Complete blood count
● Different labs have different normal values
● Correlate with findings with your patient
● Any abnormalities in two cell lineages -->

bone marrow aspiration (exclude nutritional
anemia, sepsis)
Common Hematologic
Diseases
Disease CBC Finding Clinical Profile
Iron deficiency Microcytic, hypochromic Females in reproductive age

anemia (IDA) anemia group
Thrombocytosis Persons with chronic blood loss,
CKD
IDA in elderly male: colon CA
Megaloblastic Big RBCs (high MCV) Alcoholics, vegetarians
anemia Gastric bypass surgery
Hemolysis Low hemoglobin, high Pallor, jaundice

RDW/retic ct, high serum Signs of sepsis
indirect bilirubin
Anemia of Normocytic, normochromic CKD, CLD, malignancy
chronic disease anemia (may proceed to
hypo, micro)
When Should You Transfuse?
Indications Cutoffs/Details Remarks
Acute blood loss > 40% blood If 30-40%, may transfuse if elderly,
volume with pre-existing anemia or
comorbids
Hemoglobin levels < 60 mg/L If Hgb 60-100, may transfuse if with
symptoms, ongoing bleeding or
elderly
Chronic anemia < 60 mg/L May transfuse if Hgb < 70, if with
ongoing blood loss, cardiac/pulmo/
cerebrovascular risk factors
Peri-operative If Hgb < 70 and asymptomatic, may transfuse if with
scheduled surgery is expected to produce significant
blood loss or if anesthetic risk is high
New York State Council on Human Blood and Transfusion Services Guidelines 2004
When Should You Transfuse?
● Transfuse whole blood or pRBC + FFP + cryosupernate
for significant blood loss
● FFP transfusion - hemophiliacs*, HUS/TTP, dengue

hemorrhagic fever
● Platelet transfusion
● Platelet count < 10 x 109/L
● Platelet count < 50 x 109/L if with bleeding or for surgery
* Better to transfuse cryoprecipitate (Hemophilia A), cryosupernate

(Hemophilia B) or specific factor components
Hazards of Blood Transfusion
● HIV, HBV, HCV
● Volume overload
● Transfusion reactions
● Hypocalcemia, hyperkalemia, hypothermia
● Be careful!
Questions?

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Laboratory Interpretation

Diana Tamondong-Lachica, MD, FPCP

25 y/o, female patient with Urinalysis result showing:

Which part of the kidney is most likely injured ?

The patient most likely has:

What is the Creatinine Clearance of the patient ?

To which Stage of Chronic Kidney Disease

White Pus, Chyle, Phosphate crystals

Pink / red / brown Red blood cells, Hemoglobin,

Yellow / Orange Bilirubin, B complex, Rifampicin,

Brown / black Methemoglobin, melanin

Blue / green Pseudomonas, Dye, Chlorophyll

Normal Clinical Value

Turbidity Clear Infection, crystals.

Normal values Comments

Acidic urine – uric acid crystals

Urine negative Regular Dipsticks detects only

24 hr urine collection – cumbersome, prone to

Albumin / creatinine ratio is a simple and accurate

Urine Electrophoresis – to determine type of protein

• Marker of silent DM nephropathy

• Significant predictor or overt nephropathy

• First manifestation of injury to the

Cells Red blood cells, white blood cells,

Organisms Bacteria, yeasts, trichomonas

Leucocytes 1-4 /HPF UTI, interstitial nephritis

Erythrocytes 0-2 /HPF Stones, obstruction, UTI,

Hyaline casts FEW Dehydration

Course granular NONE CKD

WBC casts NONE Pyelonephritis

RBC cast NONE Glomerulonephritis

May originate anywhere from the glomerulus to the

Normal: RBC in the urine is between 0 – 2 / HPF

Abnormal: > 3 RBC / HPF

Shape of RBC is important:

Hematuria with Proteinuria , RBC Glomerular pathology

Hematuria coincident with URTI, IgA nephropathy

Hematuria days or weeks after Acute post-streptococcal

Hematuria with Pyuria UTI, Glomerulonephritis

Hematuria, Crystals Stone disease

Eosinophils – seen in allergic interstitial nephritis,

TUBULES Abnormal urine specific Urinary tract infection

VASCULAR Bland sediments Hypertension

Features Nephrotic Nephritic

JVP norma/low raised

HEMATURIA may/may not occur +++

RBC CASTS absent Present

ALBUMIN low Normal/sl. decreased

● Mainly derived from metabolism of creatine/creatine

● Produced in almost constant rate

● Steady state concentration dependent on renal

(140 – Age ) X Wt in kgs

*Multiply result by 0.85 for female

CrCl normal values = 90 – 120 ml/min

SERUM CREATININE ALONE IS NOT A GOOD

● CrCl = (Ucr)(V) / Pcr

● Quick estimation of creatinine clearance use

Decrease levels – liver disease, pregnancy

Laboratory Interpretation  