1120106-尿液常規及生化檢查之臨床應用~特殊個案及臨床分析-陳金順副院長.pdf

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尿液常規及生化檢查之臨床應用
：特殊個案及研究分析
演講者：高雄榮總陳金順醫師
時間：112年1月6日12:30
地點：高雄醫師公會大禮堂

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O U T L I N E
01 尿液分析臨床應用之過往歷史
02 尿液分析之介紹、文獻回顧及研究分析
2-1.尿液常規
2-2.尿液生化
04 結論
03 尿液分析之近期進展：精準及智慧醫療

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01
PART
尿液分析臨床應用之過往歷史

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01.尿液分析臨床應用之過往歷史
Ancient time(古代史):
BC: clay tablets
Hindu cultures: sweet urine:DM
Bubbles: kidney diseases
Urine: a filtrate of the humors
The middle Ages(中世紀) (AD500-1500) :
AD885-955: De urinis: textbook: urine as diagnostic tool
AD 1165-1213: Matula (jorden): color, consistency, clarity
AD 1275-1328:warned of the dangers of diagnosis based on urine alone
The Renaissance(現代史) (1450-1600) :
AD1491: Fasciculus Medicinae (Germany) vs Merck Manual
Leeches vs Physician: Pisse Phophets
Uroscopy is no longer practiced, but urine analysis remains an effective
diagnostic tool, with a long and colorful history
Kidney International 2007:71:384-387

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尿液分析是醫院中最常做的檢驗項目之一，臨床上
通常將尿液分析應用於疾病篩檢、診斷及追蹤工具
篩檢：篩選腎臟及代謝性疾病（如酸鹼、血壓、
糖分異常等…）
診斷：診斷腎臟、泌尿道異常及其他系統性疾病
（如內分泌、癌症、感染、紫質症等…）
追蹤：腎臟及代謝性疾病之追蹤工具。
01.尿液分析臨床應用之過往歷史

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02
PART
尿液分析之介紹、文獻回顧
及研究分析
2-1.尿液常規
2-2.尿液生化

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尿液之形成
尿液之成分
尿液分析之時機及方法
尿液之分析及判讀
物理特性
化學特性
顯微鏡檢
02.尿液分析之介紹、文獻回顧及研究分析尿液常規

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尿液之形成
尿液之成分
物理特性
化學特性
顯微鏡檢

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尿液之形成
腎臟之解剖學

1/5
1/5
Cardiac
output
Renal
blood flow
GFR
125 cc/min
水+溶質水+溶質
過濾吸收分泌排出
Urine
600~1800 cc/day
水+溶質
1/5

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尿液之形成
尿液之成分
物理特性
化學特性
顯微鏡檢

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尿液之成分
溶質-代謝產物
Carbohydrate
Lipid Water & CO2
Mineral Electrolytes
Protein
Nucleic acid Urea, Creatinine, Uric acid, Other inorganic solutes
Fundamentals of Urine & Body Fluid analysis, 5th-ed., 2022

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有形物質：細胞、圓柱體、結晶、微生物有機體
Urinalysis and Body Fluids, 7th-ed., 2020
尿液之成分
 尿液成分：預估3,079種成分
 尿療法?

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尿液之成分
物理特性
 Color
 Turbidity
 Odor
 Specific gravity
尿液常規
化學特性
 pH
 Glucose
 Occult blood
 Protein
 Ketone
 Bilirubin-urobilinogen
 Leukocyte
 Nitrite
顯微鏡檢
 Cell
 Cast
 Crystal
 Microorganism

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尿液之形成
尿液之成分
物理特性
化學特性
顯微鏡檢

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尿液分析之時機及方法
尿液分析是醫院中最常做的檢驗項目之一，臨床上
通常將尿液分析應用於疾病篩檢、診斷及追蹤工具
篩檢：篩選腎臟及代謝性疾病（如酸鹼、血壓、
糖分異常等…）
診斷：診斷腎臟、泌尿道異常及其他系統性疾病
（如內分泌、癌症、感染、紫質症等…）
追蹤：腎臟及代謝性疾病之追蹤工具。

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尿液分析之時機及方法-檢體收集
Urinalysis and Body Fluids, 7th-ed., 2020

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尿液分析之時機及方法-檢體保存(1)
CLSI (formerly, NCCLS) Guidelines recommend testing urine within two hours of its
collection. However, refrigeration or chemical preservation of urine specimens may
be utilized if testing or refrigeration within a two-hour window is not possible.
使用不同試劑保存，
因應不同目的。

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尿液分析之時機及方法-檢體保存(1)

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尿液之形成
尿液之成分
物理特性
化學特性
顯微鏡檢

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尿液之分析及判讀
 Color
 Turbidity
 Odor
 Specific gravity
物理特性(Physical Features)

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Scand J Clin Lab Invest, 2000; 60: 1-96
Physical Features—Color (1)

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Physical Features--Color (2)
Scand J Clin Lab Invest, 2000; 60: 1-96

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Physical Features--Turbidity
Fundamentals of Urine & Body Fluid analysis, 2nd-ed., 2003; p107

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Physical Features--Odor
Fundamentals of Urine & Body Fluid analysis, 2nd-ed., 2003; p108
鼠臭
皮衣
楓糖
餿
腐爛
啤酒花
臭腳味
薄荷

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 The ratio of its weight to that of an equal volume of water at the same
temperature
代表腎臟濃縮功能
正常： 1.005 ~ 1.035
異常：< 1.005  尿崩症、抗利尿激素分泌不正常
> 1.035  脫水、少尿症、使用顯影劑等
Physical Features--Specific Gravity (尿比重)
尿比重與尿溶解度(osmolality)有一定比例關係( × 40)

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Physical Features
--Specific Gravity
water diuresis solute diuresis
Hyponatremia
實驗室：鈉離子
症狀：尿量異常
異
常

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 pH
 Glucose
 Occult blood
 Protein
 Ketone
 Bilirubin-urobilinogen
 Leukocyte
 Nitrite
化學特性(Chemical Features)

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正常範圍：4.0～8.0，平均為6.0。
異常：
< 6.0 (酸性尿) 蛋白質攝取較多、水果如Cranberry ，酸血症，泌尿道
感染(特別是大腸桿菌)，低血鉀症、飢餓、糖尿病等。
> 7.0 (鹼性尿) 高蔬果飲食、飯後，鹼血症, 因proteus造成的泌尿道感染，
尿液放置過久。
鹼性體質 vs 酸性體質??
體內血中PH：7.35~7.45
Robert Oldham Young  1億美金
Chemical Features--pH

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Acid-base disturbances: hypokalemic alkalosis with paradoxical aciduria
Acidification or alkalinization of urine is associated with specific diseases:
renal tubular acidosis
Chemical Features--pH
(+)
(-)
pCO2 < 40 mmHg, HCO3 ≤ 22 mmol/l
Metabolic acidosis
Ketones
Acidosis
- Gastrointestinal bicarbonate
loss (diarrhoea,
ureterosigmoidostomy,
pancreatic fistula, anion
exchange resins,
CaCl2/MgCl2 intake)
- Various causes
(hypoaldosteronism,
hyperalimentation, HCl
administration)
- Diabetic ketoacidosis
without hyperglycaemia
- Alcoholic ketoacidosis
- Fasting
- Non-Ketotic hyperosmolar
coma
- Ketoacidosis associated
with hyperglyceamia
- Renal tubular acidosis
- Interstitial nephritis
- Obstructive uropathy
- Carboanhydrase inhibitors
pCO2 < 40 mmHg, HCO3 ≥ 22 mmol/l
Respiratory acidosis
Anion gap < 12 Anion gap > 12
Urine pH > 5.5 SOSM > 295mOsm/Kg H2O
- Methanol
- Ethylene glycol
- Paraldehyde
- Lactic acidosis
- Salicylate intoxication
- Renal failure
- Alveolocapillary gas exchange
diminished
- Hypoventilation (CNS-related)
- Anatomical reasons
- Neuromuscular insufficiency
- Airway obstruction
No Yes No Yes
血中偏酸尿中偏鹼

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Chemical Features--Glucose

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Chemical Features--Glucose

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Chemical Features--Occult blood
Pseudoperoxidase activity shown by the haem moiety of haemoglobin and of myoglobin
Hemoglobin: pre-renal, renal, post-renal, menstruation
Myoglogin: muscle necrosis, rhabdomyolysis (alcoholic, neuroleptic malignant
syndrome, cocaine abuse), and polymyositis

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Hemoglobin vs. Myoglobin
Dissolving 2.8 g of ammonium sulfate in 5 ml of urine,
followed by filtration or centrifugation
 hemoglobin participate, myoglobin doesn’t not
Sediment:
RBCs exist: Yes Hemoglobin
No  Myoglobin
Hemoglobin without red cells
Myoglobin
Hemolysis
Cells have been destroyed
Chemical Features--Occult blood
OB vs RBC

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Chemical Features--Protein
Normal protein excretion < 100~150mg/dl
 40%: Tamm-Horsfall glycoprotein (uromodulin)
 40%: Albumin (distal tubular cast formation)
 15%: immunoproteins
 5%: other plasma proteins
Pathological protein
 glomerular: GN (increase permeability)
 tubular: Tubulointerstitial disease (decreased reabsorption)
 overload: monoclonal gammpathy (increased production)

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Chemical Features--Protein
Quantitative evaluation
Random Up/Ucr
24 hrs DPL
Qualitative analysis
Selectivity of proteinuria:
IgG/transferrin (<0.1, selective)
Microalbuminuria
Random
albumin/ creatinine: 30-300 ug/mg
24 hrs urine: 30-300 mg/day

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Chemical Features--Ketones
Brunzel, Nancy A. Fundamentals of Urine & Body Fluid analysis. 5th-ed. 2022

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Chemical Features--Bilirubin-urobilinogen
Normal
Urine urobilinogen: normal (< 1 mg/dl)
Urine bilirubin: normal (< 0.02 mg/dl)
Prehepatic
Urine urobilinogen: 
Urine bilirubin: negative
Hepatic
Urine urobilinogen: normal or 
Urine bilirubin: 
Postehepatic
Urine urobilinogen: 
Urine bilirubin: 

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Chemical Features--Leukocyte & Nitrite
Leukocyte esterase
Esterase activity of granulocytes
Nitrite
Nitrate
WBC: inflammation
nitrate reductase
G(-): E.coli
retention time
Nitrite
Bacteriuria
Leukocyte with bacteriuria: pyelopnephritis, cystitis, urethritis
Leukocyte without bacteriuria: trichomonas, mycoses, chlamydia,
virus, TB, and mycoplasma
Diet

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 Cell
 Cast
 Crystal
 Microorganism
顯微鏡檢(Urine Microscopy)

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Note
Before analysis: pH and osmolality should be know
higher pH cast decreased
 neutrophilic lyse
lower osmolality erythrocyte lyse
(couple microscopy with dispsticks for
hemoglobin and leukocyte esterase)
Urine microscopy

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Erythrocyte
Cell morphology--regular shape: non glomerular origin
--irregular shape: glomerular origin
Granulocytes
UTI, glomerulonephritis, acute interstitial nephritis, and
aseptic cystitis
Lymphocytes
Chronic inflammatory diseases, viral diseases, renal
transplant rejection
Macrophage
UTI, inflammation of kidney
Urine microscopy--Cell

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Eosinophili
Acute interstitial nephritis, atheroembolic renal diseases
Renal tubular cells
ATN, AIN, AGN, acute cellular allograft rejection
Urothelial cell
Deep layer: urolithiasis, bladder cancer, hydronephrosis
Superficial layer: UTI
Squamous cell
vaginal discharge
Urine microscopy--Cell

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 Form within the distal tubules and the
collecting ducts of the kidneys from
the aggregation and transformation
into a gel of the fibrils of Tamm-
Horsfall glycoprotein.
Urine microscopy--Cast
American Family Physician, 2005; 71: 6 1153-62

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Urine microscopy--Crystal
In most instances, the finding of crystals is not clinically relevant.
Clinical value in subpopulation
Recurrent renal stone formers
Acute renal failure (calcium oxalate crystalluria)
Acute uric acid nephropathy
Ethylene glycol poisoning
Severe liver disease
Tyrosine and leucine crystals
Deficinecy of xanthine oxidase
Xanthine crystalluria
Uric acid
Triple
phosphate
Calcium
Oxalate leucine crystals
Tyrosine
crystals

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Urine microscopy--Microorganism
Bacteriuria
Trichomonas
vaginalis
Candida
Eggs of Schistosoma
haematobium
Lipid droplet
Bacteria
UTI
GI contamination
Bacteriuria without leukocyte: investigation again
Yeast
Urethral: actual infection (immunosuppressive)
Vaginal infection
Fat
Lipiduria: nephrotic syndrome
Trichomona vaginalis
 Parasitic gynecological infection
Parasites
Parasitic infection

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Urolithiasis (2019) 47:99–105

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Urolithiasis (2019) 47:99–105

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02
PART
尿液分析之介紹、文獻回顧
及研究分析
2-1.尿液常規
2-2.尿液生化

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02.尿液分析之介紹、文獻回顧及研究分析尿液生化

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腎臟：電解質異常、酸鹼異常
荷爾蒙：血壓異常(續發性高血壓)
血液腫瘤：蛋白質異常
毒物：重金屬、藥物

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1以鉀離子為例：
Input:
Redistribution:
Output:
2名詞介紹：
Spot urine:TTKG
FEK 、UK / Ucr
24 hrs urine:
須使用尿中osmolality & Cr
作計算或校正
FE： filtration excretion ratio
Filtration GFR × 血中濃度 × 1440min
Excretion 尿中濃度 × 一天尿量
Mayo Clin Proc. March
2021;96(3):744-762
=

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腎臟基本生理功能及其測定

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生理功能
基本檢驗
血液尿液
腎功能
腎絲球 eGFR, BUN/Cr Albuminuria
腎小管(近曲小管) Glucose, UA Glucosuria, FEUA
體液平衡（水及鈉） POsm USpGr, UOsm, UNa
代謝性酸中毒 PAG UpH, UAG, Ketones
代謝性鹼中毒及鉀 Mineralocoticoids TTKG, 24 hrs K
內分泌
急性腎衰竭 IgX, C3, ANA FENa, Cast
慢性腎衰竭 iPTH, Ca, iP, CO2, Hgb Casts
腎臟基本生理功能及其測定

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急性慢性
病史
系統性疾病
藥物
感染
身體檢查
皮膚
鞏膜
實驗室檢查
尿液--U/R：Cast
FENa, Uosm
血液--B/R：Hgb
--SMA：CO2、Ca、iP
--內分泌：iPTH
影像學檢查
超音波：Kidney size
腎臟病理學檢查
眼底檢查
藉由此表之總整分析，快速分析腎病變是急性或慢
性
To establish diagnosis, rule out reversible causes

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Singapore Med J 2017; 58(5): 267-271

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03
PART
尿液分析之近期進展：
精準及智慧醫療

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03.尿液分析之近期進展：精準及智慧醫療

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Nature Reviews | Urology volume 19 | April 2022 | 219

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npj Digital Medicine (2019) 2:109

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Bi et al., 2022, Cell Reports 38, 110271

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04
PART
結論
04.結論

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Hyaline cast
Waxy cast
Granular cast

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Erythrocyte
cast
Leukocyte
cast

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Calcium Oxalate
Triple phosphate
Calcium phosphate
Uric acid

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Hoilat GJ, John S.2022 Aug 14. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–
.PMID: 32491371

1120106-尿液常規及生化檢查之臨床應用~特殊個案及臨床分析-陳金順副院長.pdf

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1120106-尿液常規及生化檢查之臨床應用~特殊個案及臨床分析-陳金順副院長.pdf