Denielle

Genesis B. Camato

VII. URINE SCREENING FOR METABOLIC DISORDERS

ANALYSIS O F URINALYSIS AND BODY FLUIDS | REVIEWER

OVERFLOW VERSUS RENAL DISORDERS

PHENYLALANINE TYROSINE DISORDERS

TWO CATEGORIES IN RENAL DISORDERS

a)

OVERFLOW TYPE
Results from the disruption of a normal metabolic pathway
that causes increased plasma concentrations of nonmetabolized substances.

PHENYLKETONURIA

b)

Metabolic defects cause production of excessive amounts

of melanin.

RENAL TYPE

caused by malfunctions in the tubular reabsorption

mechanism (see Chap 8; Tubular Disorders)

Metabolic Disturbances- most encountered abnormalities that

produce urinary overflow of substances involved in CHON and CHO
metabolism

Inborn Error of Metabolism- disruption of enzyme function

can be caused by failure to inherit the gene to produce a
particular enzyme, or by organ malfunction from disease or toxic
reactions.

ABNORMAL METABOLIC CONSTITUENTS FOR CONDITIONS DETECTED IN

THE ROUTINE URINALYSIS

Most well-known of the aminoacidurias; may lead to mental

retardation if remain undetected
first identified in NORWAY by Ivan Folling, 1934
Mousy-odor to urine
Increased amts of keto-acids including phenylpyruvate
Decrease production of tyrosine and its pigmentation
metabolite, melanin
Failure to inherit gene, phenyalanine hydroxylase
PHENYLALANINE, major constituent of milk from infants
diet

GUTHRIE TEST, most well-known test for PKU

Blood from heelstick is absorbed into filter paper; blood
impregnated disks are then placed on culture media streaked with
Bacillus subtilis
Beta-2-thienylalanine, inhibitor of B. subtilis
Tube test based on ferric chloride reaction; addition of ferric
chloride to urine with phenylpyruvic acid produces permanent
blue-green color

TYROSYLURIA

MAJOR DISORDERS OF PROTEIN & CARBOHYDRATE METABOLISM

ASSOCIATED WITH ABNORMAL URINARY CONSTITUENTS CLASSIFIED
AS TO FUNCTIONAL DEFECT

Accumulation of excess tyrosine in the plasma (tyrosinemia)

Urine may contain excess tyrosine or its degradation
products p-hydroxyphenylpyruvic acid & phydroxyphenyllactic acid
most frequently seen is a transitory tyrosinemia in
premature infants; under development of the liver function
Reaction can be distinguished from the PKU reaction in the
ferric chloride tube test because green color fades rapidly
when tyrosine is present
Nitroso-naphthol test, recommended urinary screening
test, orange-red is positive color

ALKAPTONURIA

AMINO ACID DISORDERS

R
R
R
R
R
R
R
R
R

Phenylketonuria (PKU)
Tyrosinuria
Alkaptonuria
Melanuria
Maple syrup urine disease
Organic acidemias
Indicanuria
Cystinuria
Cystinosis

Observed form urine of patients that has darkened urine

after becoming alkaline from standing at room
temperature; described by GARROD (1902)
alkali lover or alkaptonuria term adopted
Failure to inherit the gene to produce the enzyme
homogentisic acid oxidase
Brown-stained or black-stained cloth diapers; in later life
brown pigment becomes deposited in body tissues
(particularly in ears)
Ferric chloride test blue color
Benedicts test/ Clinitest yellow color (indicating presence
of reducing substance)
More specific screening test for urinary homogentisic acid is
to add alkali to freshly voided urine to observe darkening of
the color
Addition of silver nitrate and ammonium hydroxide will also
produced black urine

Denielle Genesis B. Camato

VII. URINE SCREENING FOR METABOLIC DISORDERS

ANALYSIS O F URINALYSIS AND BODY FLUIDS | REVIEWER

MELANURIA

MELANIN- the pigment responsible for the dark color of

hair, skin, and eyes. Deficient production of melanin results in
albinism
Increased urinary melanin will produced darkening of urine
(just like homegentisic acid); elevation of urine melanin is a
serious finding that indicates the overproliferation of the
normal melanin-producing cells (melanocytes) producing
malignant melanin.
5,6-dihydroxyindole- colorless precursor of melanin
Ferric chloride test gray or black precipitate
Sodium nitroprusside test red color
Intereference sources: Acetone & Creatinine; to avoid,
just add glacial acetic acid w/c will cause melanin to revert to
a green-black color whereas acetone turns purple and
Creatinine becomes amber.

BRANCHED-CHAIN AMINO ACID DISORDERS

The branched-chain amino acids differ from other amino
acids by having a methyl group that branch from the main
aliphatic carbon chain.
2 GROUPS:

Accumulation of one or more of the early amino acid

degradation products g eg: Maple Syrup Urine Disease
Disorders in the other group are termed organic acidemias
and result in accumulation of organic acids produced further
down in the amino acid metabolic pathway

TRYPTOPHAN DISORDERS

The major concern of the urinalysis laboratory in the

metabolism of tryptophan is the increased urinary excretion
of the metabolites indicant and 5-hydroxylindoleacetic acid
(5-HIAA)

MAPLE-SYRUP URINE DISEASE

INDICANURIA

Cause by an inborn error of metabolism, inherited as an

autosomal recessive trait.
Amino acids involve: leucine, isoleucine, & valine
Three amino acids in liver (-ketoisovaleric, ketoisocaproic, & -keto--methylvaleric). Failure to
inherit the gene for the enzyme necessary to produce
oxidative decarboxylation of these keto acids results in their
accumulation in blood and urine.
Urine produces strong odor resembling maple syrup, which is
caused by the rapid accumulation of keto acids in urine
2,4-dinitrophenylhydrazine (DNPH)- screening test most
frequent performed for keto acids yellow turbidity or
precipitate
Interference: large dose of ampicillin

5-HYDROXYINDOLEACETIC ACID (5-HIAA)

ORGANIC ACIDEMIAS

Tryptophan usually enters the body to be reabsorbed for

use of the body in the production of protein or is converted
to indole by the intestinal bacteria & excreted in the feces;
however if there are intestinal disorders (eg: obstruction,
Hartnup disease, etc) increases amount of tryptophan are
converted to indole.
Hartnup disease g blue staining of infants diapers refer to
as blue-diaper syndrome
Ferric chloride g deep blue or violet color; can subsequently
be extracted into chloroform

SEROTONIN- used for the stimulation of smooth muscles;

produced from tryptophan by the argentaffin cells in the
intestine and is carried through the body primarily by the
platelets; major constituent of foods: bananas, pineapples,
tomatoes
When carcinoid tumors involving the argentaffin
(enterochromaffin) cells develop, excess amounts of
serotonin are produced, resulting in the elevation of urinary
5-HIAA levels
Nitrous acid + 1-nitroso-2-naphthol g urine with 5-HIAA =
purple to black color
Normal daily excretion of 5SEROTONIN m olecular
structure
HIAA: 2-8 mg (argentaffin cells
tumors will produce from 160 to
628 mg/24 hours)
Specimen: Random or First morning
urine
Specimen: if 24 hour urine g preserved with HCL or Boric
Acid
Interference: Phenothiazines and Acetanilids

Denielle Genesis B. Camato

VII. URINE SCREENING FOR METABOLIC DISORDERS

ANALYSIS O F URINALYSIS AND BODY FLUIDS | REVIEWER

CYSTINE DISORDERS

PHORPHYRIN DISORDERS

CYSTINURIA- defect in the renal tubular transport of

amino acids
CYSTINOSIS- inborn error of metabolism
A noticeable odor of sulfur may be present in the urine in
disorders of cystine metabolism

CYSTINURIA

Marked by elevated amounts of the amino acid cysteine in

the urine
Inability of the renal tubules to reabsorbed cysteine
filtered by the glomerulus
2 MODES:
R
Reabsorption of all four amino acids (cysteine,
lysine, arginine, & ornithine)
R
The other in which only cysteine & lysine are not
reabsorbed
65% of these people can be expected to produce calculi
early in life
Cyanide-Nitroprusside- chemical screening test redpurple color
False Positives: presence of Ketones & homocystine

CYSTINOSIS

Regarded as genuine inborn error of metabolism

Incomplete metabolism of cystine results in crystalline
deposits of cysteine in many areas of the body, including the
cornea, bone marrow, lymph nodes, and internal organs
FANCONIS SYNDROME- major defect in the renal tubular
reabsorption mechanism
Urinalysis: Polyuria, Aminoaciduria, (+) test for reducing
substances, lack of urinary concentration
Progression to total renal failure
Renal transplants & use of cystine-depleting medications to
prevent cysteine build up in other tissues are extending lives

MUCOPOLYSACCHARIDE DISORDERS

HOMOCYSTINURIA

Increased urinary homocystine gives a positive result with

the cyanide-nitroprusside test
Positive cyanide-nitroprusside test result must be followed
by silver-nitroprusside test in which only homocystine will
react
The use of silver nitrate in place of sodium cyanide will
reduce homocystine to its nitroprusside reactive-form but
will not reduce cysteine.
Positive reaction in the silver-nitroprusside test confirms
the presence of homocytinuria
Specimen: Fresh Urine

Porphyrins are the intermediate compunds in the production

of heme
Three primary porphyrins: (uroporphyrin,
coproporphyrin, protoporphyrin)
Porphyrin precursors: (-aminolevulinic acid [ALA] &
porphobilinogen)
ALA, porphobilinogen & uroporphyrin are the most soluble &
readily appear in the urine.
Coporphyrin is less soluble but is found in the urine
Protoporphyrin is not seen in urine
Fecal Analysis usually performed for detection of
coproporphyrin & protoporphyrin; however to avoid false
positive BILE is more acceptable specimen.
FREE ERYTHROCYTE PORPHYRIN (FEP)- analysis of whole
blood recommended by Centers for Disease Control (CDC) as
screening test for lead poisoning
PORPHYRIAS- disorders of porphyrin metabolism; can be
inherited or acquired from erythrocytic& hepatic
malfunctions or exposure to toxic agents
Port-wine/Red color to the urine
Congenital Porphyria is sometimes suspected from a red
discoloration of an infants diapers
ERHLICHS Reaction & Fluorescence under ultraviolet
light in 550 to 600nm are two screening tests for
porphyrinuria
ERHLICHS g detection of ALA & Porphobilinogen only
Acetylacetone g added to specimen to convert ALA to
porphobilinogen prior to performing Ehrlich test
FLUORESCENT TECHNIQUE g used for other porphyrins
Ehrlich Test & Watson-Schwartz test & Hoesch testfor differentiation between presence of urobilinogen &
porphobilinogen

Glycosaminoglycans; group of large compunds located

primarily in the connective tissue.
Products most frequently found in urine are dermatan
sulfate, keratin sulphate, heparin sulphate
Hurlers Syndrome, Hunters Syndrome, San Filipippos
Syndrome- best known disorders of mucopolysaccharides
Hurler & Hunter g skeletal structure are abnormal &
there is severe mental retardation; in Hurlers syndrome
mucopolysaccharides accumulate in the cornea of the eye.
San Filippos syndrome g only abnormality is mental
retardation
Acid-Albumin & Cetyltrimethylammonium bromide
(CTAB)- most frequently used screening tests; turbidity
tests and the metachromatic staining spot tests.
Acid-Albumin & CTAB g thick, white turbidity is positive
result
Metachromatic Stain- uses basic dyes to react with acid
mucopolysaccharides (eg: Azure A dye) Positive result: BLUE
spot that cannot be washed away by a dilute acidified
methanol solution

Denielle Genesis B. Camato

VII. URINE SCREENING FOR METABOLIC DISORDERS

ANALYSIS O F URINALYSIS AND BODY FLUIDS | REVIEWER

PURINE DISORDERS

Lesch-Nyhan Disease g inherited as a sex-linked recessive

results in a massive excretion of urinary uric acid crystals
Failure to inherit the gene to produce the enzyme
hypoxanthine guanine phosphoribosyltransferase;
responsible for the accumulation of uric acid throughout the
body.
Patients suffer from severe motor defects, mental
retardation, tendency toward self-destruction, gout & renal
calculi
Uric Acid crytals resembling orange sand in diapers

CARBOHYDRATE DISORDERS

Presence of increased urinary sugar (melituria)

Pentosuria one of Garrods original six inborn errors of
metabolism; ingestion of large amounts of fruits
Presence of galactosuria indicating the ability to properly
metabolize galactose to glucose. Resulting galactosemia with
toxic intermediate metabolic products results in infant
failure to thrive, combined with liver disorders, presence of
cataracts & severe mental retardation.
Lactosuria may be seen during pregnancy
Fructosuria associated with parenteral feeding