Kidney Information and Courses from MediaLab, Inc.

Slide-based ANA testing using a cell substrate started in the 1950s and continues to be the gold standard method. In the early days of ANA testing, rodent tissue (stomach, liver and/or kidney) was commonly used as the substrate. Rodent tissue however had several drawbacks such as small cell size, a lack of dividing cells (mitotics) and poor antigen expression that made interpretation of ANA patterns difficult. In the 1980s, cultured cell lines were examined for utility as an ANA substrate and the human epithelial- like cell line HEp-2 gained popularity. HEp-2's advantages over rodent tissue are: A large nucleus Better antigen expression Abundant mitotic cells that assist in interpretation of the ANA pattern (if grown properly).More recently a cell line called HEp-2000® has become popular for ANA detection. HEp-2000® is a HEp-2 cell line that has been transfected with the cDNA for overexpression of the SSA/Ro antigen. This results in a substrate with all of the original advantages of HEp-2 plus an added advantage of increased sensitivity for detection of antibodies directed to the SSA/Ro antigen and the ability to identify these clinically significant antibodies during the screening process.(Ref4)It has also been demonstrated that antibodies to SSA/Ro develop early in the disease process.(Ref5) Perhaps most importantly, if a woman has anti-SSA/Ro antibodies and becomes pregnant there is a risk of the antibodies crossing the placenta, resulting in the fetus developing neonatal lupus and congenital heart block in utero.The advantage of using these transfected cells is documented in the current Clinical and Laboratory Standards Institute (CLSI) guidelines for ANA testing. Here they note the "dramatically increased" sensitivity of transfected cells for the detection of SS-A/Ro and the unaltered effect of transfection on other ANA patterns.(Ref6)

Thrombotic thrombocytopenic purpura (TTP) is an uncommon, but very serious consumptive platelet disorder. Its cause is unknown, but there are several possible precipitating factors including infection, carcinoma, and pregnancy. More women than men are affected by TTP. If left untreated, the mortality rate is in excess of 90% due to multiorgan failure. Hemolytic uremic syndrome (HUS) is also a platelet consumptive disorder. HUS is thought by some to be the same condition as TTP because both disorders have the same underlying pathology. However, HUS is more often associated with renal failure and TTP with neurological manifestations including visual impairment, weakness, headache, dizziness, disorientation. seizures, or coma. Microangiopathic hemolytic anemia, thrombocytopenia, and fever is associated with both TTP and HUS. The patient's condition can deteriorate rapidly while these symptoms are becoming evident. HUS is usually seen in children; it is the most common cause of acute renal failure in children. Patients may have bloody diarrhea and symptoms resembling colitis. Diarrhea-related HUS is usually associated with ingestion of undercooked beef contaminated with Ecoli O157:H7; it is the Shiga-like toxin from this serotype that causes the illness. Some patients may have long term kidney dysfunction as a result ofthis virulent infection. For patients who have experienced renal failure, dialysis may be required.

Atypical teratoid/rhabdoid tumor is a highly malignant brain tumor with a poor prognosis that is genetically related to the malignant rhabdoid tumor of the kidney.Approximately 30% of these patients will have intracranial extension of their tumor at diagnosis with tumor cells present in the cerebrospinal fluid.These tumor cells are usually found in small clusters and clumps and have highly dysmorphic nuclei with prominent nucleoli.

In the metamyelocyte stage, the cytoplasm and nucleus continue to decrease in size. The cytoplasm achieves full secondary granule content. The chromatin becomes more dense, knotted, and compact, while the nucleus begins to indent and acquire the familiar "kidney bean" shape. By the end of the stage, the cell will be similar in size to a mature neutrophil with similarly cytoplasmic granularity.The top image to the right shows a fairly classic metamyelocyte. Observe the indented kidney bean-shaped nucleus and neutrophil-colored cytoplasm. Notice the clumped aggregates of chromatin in each pole of the nucleus. The vacuolated cytoplasm in this cell is an indication of toxic stress.In the bottom image to the right, notice the metamyelocytes (see red arrows) and their chromatin patterns. The patterns becomes more dense and clumped as the metamyelocytes continue to mature to the band neutrophil stages (see blue arrows).

Myoglobin can also be used as a diagnostic indicator of an AMI. Myoglobin is an oxygen-binding protein in cardiac and skeletal muscle. It is released earlier after muscle injury than cardiac troponins and CK-MB and returns to normal faster than either of these other markers. It rises within 2 - 4 hours after chest pain, peaks in 6 - 12 hours, and is usually normal within 24 - 36 hours.Because of myoglobin's increase after skeletal muscle injury, it lacks the needed specificity for diagnosis of ACS and an AMI. False-positive elevation of myoglobin may also occur in a patient with impaired renal function since myoglobin is cleared through the kidneys.Myoglobin reference ranges for adults when an immunoassay method is used are approximately: Male 17-106 ng/mL Female 1-66 ng/mL Variation in ranges may be seen with different measurement methods.

BNP, as an active protein hormone, has a short biological half-life of 20 minutes. NT-ProBNP, inactive fragment, has a half-life of 1-2 hours. Both are increased in CHF and both levels correlate to the severity of condition. In the future these two hormones may be used as prognostic indicators in ACS also; studies have shown that levels predict cardiac mortality and adverse cardiac events in patients with ACS.Because of its longer half-life, there are advantages to measuring NT-ProBNP over BNP. In CHF patients receiving exogenous and synthetic BNP for treatment, BNP levels may be affected while NT-ProBNP will not be affected. NT-ProBNP is thought to be primarily cleared by kidneys and therefore falsely elevated in severe renal disease.

The arrow in this slide is pointing to a monocyte. The nucleus has an open chromatin pattern which gives it a spongy appearance. The other two nucleated cells could be classified as macrophages (histiocytes) because the nucleus in each cell is oval or kidney bean-shaped and the cytoplasm is very irregular. After circulating in the blood for one to three days, monocytes enter the tissues. The tissue form of the monocyte is called a macrophage or histiocyte.

A chemical urinaylsis reagent strip, also called a dipstick, for screening urine is a narrow band of paper which has been saturated with chemical indicators for specific substances or properties. Depending on the product being used, chemical urinalysis reagent strips may include test indicators for glucose, bilirubin, ketones, specific gravity, blood, pH, protein, urobilinogen, nitrite, and leukocyte esterase. The results obtained from urine screening using chemical urinalysis strips can indicate the patient's carbohydrate metabolism status, kidney and liver function, urinary tract infection, and acid-base balance. Most chemical urinalysis reagent strips can be read visually and do not require instrumentation for automatic reading, though many laboratories utilize instruments for this purpose. When performing chemical urinalysis reagent strip analysis, the directions must be performed exactly. Accurate timing is paramount in order to achieve appropriate and optimal results. In addition, the reagent strips must be stored properly in their containers with the lid tightly closed to maintain reagent reactivity. It is always essential to utilize well-mixed urine which has been collected within 2 hours of analysis.Always read the package insert for your particular brand of chemical urinalysis reagent strip, as each manufacturer may have slightly different instructions and interpretations.

The presence of an increased amount of protein in a urine specimen is often the first indicator of renal disease. Proteinuria may signal severe kidney damage, be a warning of impending kidney involvement, or be transient and unrelated to the renal system. Further quantitative testing of urine for protein may be needed to determine the significance of the proteinuria. Proteinuria related to kidney impairment may be due to glomerular membrane damage caused by toxic agents, immune complexes found in lupus erythematosus, or streptococcal glomerulonephritis. The amount of protein present in urine samples from patients with glomerular damage usually ranges from 10-40 mg/dL. If the urinary protein is due to a disorder that affects tubular reabsorption, the urine protein quantities will be much greater. In patients with multiple myeloma, proteinuria is due to the excretion of the Bence Jones protein. This low molecular weight protein produced by a malignant clone of plasma cells circulates in the blood and is filtered in the kidneys in quantities exceeding the tubular capacity. This excess protein is excreted in the urine.

The nitrites portion of the chemical reagent strip provides a rapid screening test for the presence of gram-negative bacteria that are often responsible for urinary tract infections. Urine cultures are still needed to confirm the diagnosis and monitor any urinary tract or kidney infection. Diagnosis and treatment of cystitis (bladder infection) is important because, if left untreated, it may result in kidney damage, impairment of renal function, hypertension and/or septicemia.

The presence of protein in a urine specimen can have serious implications. It may signal severe kidney damage, be a warning of impending kidney involvement, or be transient and unrelated to the renal system. Further quantitative testing of urine for protein may be needed to determine the significance of the proteinuria.

Liver damage or an obstructed bile duct allows conjugated bilirubin to enter the circulation and ultimately to appear in the urine. Patients with clinical jaundice due to hepatitis or cirrhosis will have bilirubinuria. If the jaundice is due to red cell destruction, there is an increase in unconjugated bilirubin which the kidneys cannot excrete.

No blood is found in the urine of healthy individuals although samples from menstruating females, frequently, but not always, test positive for blood. Hematuria is associated with renal or genital urinary disorders in which the bleeding is the result of irritation to the involved organs or trauma. Examples include renal calculi, pyelonephritis, glomerulonephritis, tumors, trauma or exposure to toxic chemicals or drugs and/or strenuous exercise. Hemoglobinuria may be due to the lysis of red cells within the urinary tract. If it is caused by intravascular hemolysis, the hemoglobin is then filtered through the glomeruli. In the normal individual, the hemoglobin molecule attaches to haptoglobin and in this way bypasses the kidney filtration system. When the hemoglobin/haptoglobin system is overwhelmed, as in cases of hemolytic anemia, severe burns, transfusion reaction, infection or strenuous exercise, hemoglobin passes into the urine.

Early detection of bacteria is important in order to prevent cystitis from developing into inflammation or infection involving the kidney and renal pelvis. The nitrite portion of the test strip can be used to screen individuals who are at risk for developing urinary tract infections, such as diabetics, persons with recurrent infections, or pregnant women. The test is also useful in evaluating the success of antibiotic therapy that is used to treat a bladder infection.

Severe proteinuria (greater than 3.5 g/day) is characteristically seen in patients with glomerulonephritis, lupus nephritis, lipoid nephrosis, and severe venous congestion of the kidney. Moderate proteinuria (0.5-3.5g/day) is seen in nephrosclerosis, multiple myeloma, diabetes nephropathy, malignant hypertension, and pyelonephritis with hypertension. Mild proteinuria (less than 0.5 g/day) may be seen with polycystic kidneys, chronic pyelonephritis, benign orthostatic proteinuria, and some renal tubular diseases. Transient proteinuria can also be due to physiologic conditions such as stress, exercise, cold exposure, and fever, in the absence of renal disease.

The presence of significant amounts of glucose in the urine is called glycosuria (or glucosuria). The amount of glucose present in urine is dependent upon the blood glucose level, the rate of glomerular filtration, and the degree of tubular reabsorption of the sugar. Usually glucose will not be present in the urine until the blood level exceeds 160-189 mg/dL, which is the normal renal threshold for glucose. The main reason for glycosuria is an elevated blood glucose level (hyperglycemia). Diabetes mellitus is the most common cause of hyperglycemia. However, stress, obesity, brain injury, myocardial infarction, hyperthyroidism, pregnancy, and a lowered renal threshold due to kidney damage can all cause glycosuria.

The PAS staining procedure is most commonly used in the clinical histology laboratory to demonstrate glycogen deposits in the liver. Glycogen granules may also be visible in tumors of the bladder, kidney, ovary, pancreas, and lung. Basement membranes, which are present in various tissues in the body, may also be visualized through the PAS staining procedure. Several disorders can be identified through the demonstration of abnormal basement membranes. The PAS staining procedure can also demonstrate fungi in tissue samples due to the high carbohydrate content of the organisms cellular walls. Neutral mucins in the gastrointestinal tract and some epithelial mucins will also give a PAS-positive staining reaction.

Reticular fibers support body organs like the liver, spleen, and kidney. The Gordon and Sweet's silver staining method is used to demonstrate abnormal reticular fiber patterns that may indicate cirrhosis or necrosis of the liver. This is why reticular stains are often requested on liver biopsies. Abnormal reticular fiber patterns may also indicate the presence of certain tumor types in the liver, spleen, or kidney.

Specialists in immunohematology perform all testing prior to blood transfusions and work to prevent transfusion infections. They also investigate any post-transfusion reactions. This specialty includes all lab procedures performed in the specialty of histocompatibility. Specialists in clinical chemistry analyze body fluids such as blood, urine, and spinal fluid to determine the chemical makeup, including the amount of carbohydrates, proteins, enzymes, and trace elements. The special covers urine microscopics and chemical evaluation of the liver, kidneys, lungs, heart, and other vital organ systems. This specialty also covers all testing performed in the specialties of radioassay and blood gas analysis. Specialists in blood banking can perform all immunohematology testing as well as testing from the specialties of clinical chemistry, hematology and serology/immunology that relates to donor blood. Clinical laboratory personnel who are licensed in the specialties of immunohematology, clinical chemistry, hematology, and serology / immunology may perform all tests in the blood banking specialty.

Laboratory specimens that are unlikely to cause disease and do not meet the criteria for category A or B substances are not subject to Division 6.2 regulations. Specimens for which the hazardous materials regulation (HMR) does not apply include human or animal samples (including, but not limited to, secreta, excreta, blood and its components, tissue and tissue fluids, and body parts) being transported for routine testing not related to the diagnosis of an infectious disease. This includes specimens that are being sent for:drug or alcohol testing cholesterol testing blood glucose level testing prostate specific antibody (PSA) testing testing to monitor kidney or liver function pregnancy testing tests for diagnosis of non-infectious diseases such as cancer biopsies The US Department of Transportation (DOT) has no "Exempt Specimen" classification and there are no DOT guidelines for packaging non-regulated specimens.* According to the DOT, in the U.S., if a package is marked as "Exempt Human/Animal Specimen" the understanding is that it contains no infectious substance. However, both IATA and the US Postal Service (USPS) have these requirements for packaging exempt specimens: Packaging IssueIATAUSPSType of packaging requiredTriple packagingTriple packagingOuter containerOne dimension must be a minimum of 100 mm X 100 mm (approximately 4 x 4 inches) Must be able to survive a drop test of 4 feet One dimension must be a minimum of 100 mm X 100 mm (approximately 4 x 4 inches) Must be able to survive a drop test of 4 feet Quantity limits: outer containerNone NoneQuantity limits: Primary receptacleNone500 mLQuantity limits: secondary packagingNone500 mL* Non-regulated specimens may become regulated because of preservatives, such as 10% formaldehyde (class 9) or 25% formaldehyde (class 8); or 25% ethanol (class 3).

TDM provides a quantitative measure of the circulating concentration of a drug. The physician determines if the dosage of the drug needs to be adjusted based on this information.If a drug concentration is determined to be outside the therapeutic range, it may be for one of the reasons listed in the table below. Reason Discussion Noncompliance Patients may (intentionally or unintentionally) not take the drug. TDM can thus help monitor compliance. Dosing errors The dose may have been erroneous or inappropriate given the patient's condition. Malabsorption The TDM result will reveal if the drug cannot be absorbed well through the gut and an alternative route of administration will be needed. Drug interactions Many drugs interfere with the absorption or metabolism of other drugs. These interactions will be revealed by TDM. Kidney or liver disease Any pathology that affects elimination will cause an elevation in a drug level that will be unmasked by TDM. Altered protein binding Changes in serum proteins can lead to big changes in the amount of free drug in serum. Variations in the genetics of drug-metabolizing enzymes can also affect drug concentrations in the body. This is the field of pharmacogenomics that will be discussed later in the course.

The following signs and symptoms are associated with acute HTR due to ABO incompatibility but can be associated with other blood group incompatibilities. ABO incompatibility typically results from patient misidentification.The more serious symptoms result from intravascular hemolysis (IVH) caused by antibodies such as anti-A and anti-B that can bind complement to C9.Signs and symptoms typically appear within minutes of the transfusion but can occur anytime during the transfusion. They may include: 1. Burning sensation along the vein being transfused (IVH due to complement activation to C9)*2. Lower back pain in the area of the kidneys (renal failure with subsequent oliguria/anuria) *3. Unexplained bleeding/oozing from a surgical site (fibrinolysis following DIC)*4. Hypotension leading to hypovolemic shock (release of vasoactive substances caused by C3a and C5a)5. Tightness in substernal area of the chest (bronchial constriction due to release of vasoactive substances caused by C3a and C5a fragments)6. Other symptoms: fever, chills, skin flushing, dyspnea, wheezing, anxiety, malaise, nausea, headache. * If untreated, these complications may lead to patient death.

•Influenza A 2009 H1N1 virus-related symptoms range from mild to severe. Many infected individuals are able to recover without medical treatment. Occasionally, some individuals require hospitalization, and these patients receive supportive care and antiviral treatment. Serious infections from the 2009 H1N1 virus have resulted in some patient fatalities, usually due to secondary bacterial pneumonia or other respiratory complications.It is important to note that approximately 70% of the individuals that require hospitalization due to H1N1 infection, have also had one or more previously recognized underlying medical condition that may compromise an effective immune response. These conditions include, but are not limited to: diabetes heart disease asthma kidney disease neurocognitive diseases pregnancy

Casts are cylindrical bodies formed either in the distal convoluted tubules or the collecting ducts of the kidney. Since the walls of the tubule act as a mold for cast formation, the width of the tubule determines the width of the cast. Thus, narrow casts are formed in the distal tubules while broad casts are formed in the collecting ducts. The matrix of all casts is thought to be Tamm-Horsfall protein, a glycoprotein secreted by the distal loop of Henle and the distal tubule. This protein entraps cells and granular material of tubular origin. Very few casts are seen in the urine of a person without renal disease, except for hyaline casts, which may be transiently present after strenuous exercise, and during fever, diuretic therapy, and congestive heart failure. A significant number of urinary casts usually indicates the presence of renal disease.

Increased numbers of cuboidal cells are found in renal transplant rejection, acute tubular necrosis (diuretic phase), injuries that interrupt blood flow to the kidney, and acute glomerulonephritis accompanied by tubular damage. Ingestion of various drugs and chemicals may cause significant tubular shedding of these epithelial cells. Cuboidal cells are easily seen in urine in cases of salicylate intoxication.

Important events that occur in an immune-mediated hemolytic transfusion reaction (HTR) include: Antibody Binding to Red Blood Cells Antibodies may be either IgM or IgG class. IgM antibodies activate complement and lead to intravascular hemolysis where free hemoglobin is released into the plasma. IgG antibodies rarely activate complement but they are often involved in effecting phagocytosis. The concentration of the antibody is directly related to the severity of the HTR. Activation of Complement The end result of complement activation is red cell lysis. Activation of Mononuclear Phagocytes and Cytokines Sensitized red cells are removed from circulation by mononuclear phagocytes. Macrophages in the spleen and Kupffner cells in the liver are active in this process. Activation of Coagulation Antibody-antigen complexes may initiate coagulation and cause disseminated intravascular coagulation (DIC). Shock and Renal Failure Hemolysis can be intravascular or extravascular. In intravascular hemolysis, free hemoglobin, RBC stroma, and intracellular enzymes are released into the blood stream. This results in hemoglobulinemia and hemglobinuria which can lead to kidney damage. In extravascular hemolysis, there is no release of free hemoglobin. Sensitized red cells are removed from the circulation by the monocytes and macrophages in the reticuloendothelial system.