A high urinary urobilinogen/serum total bilirubin ratio indicates acute hepatic porphyria in patients with abdominal pain.

Acute hepatic porphyria (AHP) has always been a diagnostic dilemma for physicians due to its variable symptoms. Correct diagnosis mainly depends on the detection of an elevated urinary porphobilinogen (PBG), which is not a routine test and highly relies on the physician's awareness of AHP. In the present study, we identified a more convenient indicator during routine examinations to improve the diagnosis of AHP. We found that AHP patients showed a significant higher "FALSE" urinary urobilinogen level caused by urinary PBG during the urinalysis when detected by strips impregnated with Ehrlich reagent (P < 0.05). And a remarkable increase in the urinary urobilinogen/serum total bilirubin ratio was observed in AHP patients. The area under the ROC curve of this ratio for AHP was 1.000 (95% confidence interval 1.000-1.000, P < 0.01). A cutoff value of 3.22 for this ratio yielded a sensitivity of 100% and a specificity of 100% to distinguish AHP patients from the controls. Thus, we proved that a "falsely" high urinary urobilinogen level that was adjusted by the serum total bilirubin level (urinary urobilinogen/serum total bilirubin ratio) could be used as a sensitive and specific screening marker for AHP in patients with abdominal pain.

Pyrroles as a Potential Biomarker for Oxidative Stress Disorders.

Redox imbalance or oxidative stress that results from both environmental and genetic factors is observed in patients with schizophrenia. Therefore, identifying markers of oxidative stress in the early stages of psychosis and using antioxidant treatments as an adjuvant to antipsychotics has important implications. The reaction of p-N,N-dimethylaminobenzaldehyde (DMAB) with pyrrole moieties has been well studied for well over a century for use as a marker of oxidative stress dysregulation. Throughout this time, pyrroles have been investigated with varying veracity in urine extracts to identify elevated levels in patients diagnosed with schizophrenia. Since the 1960's, various claims have been made with respect to what causes the colour change when DMAB is added to urine extracts. Whilst the substances from this reaction have not been fully elucidated, an objective look at most studies indicates that urobilinogen is likely to be one them. Urobilinogen has also been identified as a major interferent in our results. Both pyrroles and urobilinogen condense the DMAB reaction system (form condensation products) and are quite different. The urobilinogen detected in urine forms when gut microflora chemically reduces the bilirubin content of bile acids. In comparison, evidence suggests that the pyrrole fraction originates from the fragmentation of regulatory haem by reactive oxygen species (ROS) such as hydrogen peroxide and super and nitrous oxides. Clinical studies in our laboratories have established that pyrroles as a urine biomarker have specificity in detecting schizophrenia; however, caution must be applied as the readings are subject to interference by other DMAB active compounds that are present, such as urobilinogen. This review highlights the initial chemistry in isolating pyrroles and provides recommendations for standardised laboratory testing to ensure pyrroles are correctly measured and distinguished from other by-products.

Paper-Plastic Hybrid Microfluidic Device for Smartphone-Based Colorimetric Analysis of Urine.

In this work, a disposable paper-plastic hybrid microfluidic lab-on-a-chip (LOC) has been developed and successfully applied for the colorimetric measurement of urine by the smartphone-based optical platform using a "UrineAnalysis" Android app. The developed device was cost-effectively implemented as a stand-alone hybrid LOC by incorporating the paper-based conventional reagent test strip inside the plastic-based LOC microchannel. The LOC device quantitatively investigated the small volume (40 µL) of urine analytes for the colorimetric reaction of glucose, protein, pH, and red blood cell (RBC) in integration with the finger-actuating micropump. On the basis of our experiments, the conventional urine strip showed large deviation as the reaction time goes by, because dipping the strip sensor in a bottle of urine could not control the reaction volume. By integrating the strip sensor in the LOC device for urine analysis, our device significantly improves the time-dependent inconstancy of the conventional dipstick-based urine strip, and the smartphone app used for image analysis enhances the visual assessment of the test strip, which is a major user concern for the colorimetric analysis in point-of-care (POC) applications. As a result, the user-friendly LOC, which is successfully implemented in a disposable format with the smartphone-based optical platform, may be applicable as an effective tool for rapid and qualitative POC urinalysis.

Black urine due to urobilinogen in a patient with alcoholic pellagra.

OBJECTIVES: Systemic exposure to drugs, chemicals and foods can cause abnormally colored urine. Food exposures are typically benign, but urine discoloration due to chemicals or drugs may indicate a potentially dangerous condition. Discolored urine can also be caused by medical problems. This brief report reviews the laboratory findings leading to lactic acidosis and elevated urine urobilinogen in an alcoholic patient with pellagra. DESIGN AND METHODS: A 66-year-old male, found unconscious in his hotel room, was brought to the emergency department (ED). Upon arrival he had hypothermia, a diffuse rash and altered mental status. During ED evaluation, a urinary catheter was placed and demonstrated black urine. Medical history noted chronic alcoholism, malnutrition, and poor self-care. RESULTS: Evaluation in the hospital suggested that his rash and neurologic changes were a result of malnutrition and vitamin deficiency. A thorough biochemical workup demonstrated that elevated urobilinogen was likely causing the patient's black urine. Serum niacin concentration was undetectable. His dermatitis improved with multivitamins, thiamine, and niacin as well as topical steroids. His mental status returned to baseline and he was discharged to a skilled nursing facility following a brief hospital stay. CONCLUSIONS: The patient's abnormal laboratory results were explained by his alcoholism and poor nutrition. Furthermore, urine color returned to normal with decreased concentration of urobilinogen, after vitamin supplementation and supportive medical care.

Development of the smartphone-based colorimetry for multi-analyte sensing arrays.

Here we report development of a smartphone app (application) that digitizes the colours of a colorimetric sensor array. A conventional colorimetric sensor array consists of multiple paper-based sensors, and reports the detection results in terms of colour change. Evaluation of the colour changes is normally done by the naked eye, which may cause uncertainties due to personal subjectivity and the surrounding conditions. Solutions have been particularly sought in smartphones as they are capable of spectrometric functions. Our report specifically focuses on development of a practical app for immediate point-of-care (POC) multi-analyte sensing without additional devices. First, the individual positions of the sensors are automatically identified by the smartphone; second, the colours measured at each sensor are digitized based on a correction algorithm; and third, the corrected colours are converted to concentration values by pre-loaded calibration curves. All through these sequential processes, the sensor array taken in a smartphone snapshot undergoes laboratory-level spectrometry. The advantages of inexpensive and convenient paper-based colorimetry and the ubiquitous smartphone are tied to achieve a ready-to-go POC diagnosis.

Non-clinical safety assessment of Hwangryunhaedok-tang: 13-week toxicity in Crl:CD Sprague Dawley rats.

Hwangryunhaedok-tang (Huang-Lian-Jie-Du-Tang in Chinese, Oren-gedoku-to in Japanese) is a traditional herbal medicine with a long history of use for anti-inflammatory purposes. In this study, subchronic toxicity of daily oral administration of a Hwangryunhaedok-tang water extract (HHT) at 0, 250, 750, and 2000mg/kg for 13weeks was examined in rats. Mortality, clinical signs, and changes in body weight, food consumption, clinical signs, ophthalmological examination, urinalysis, hematology, serum biochemistry, gross observation, organ weight, and histopathology were monitored in accordance with Good Laboratory Practice and OECD guidelines. We found no mortality or abnormality in clinical signs, body weight, serum biochemistry, or organ weight in HHT-treated groups in either sex. However, there were significant changes in glucose, bilirubin, urobilinogen, protein (only male) in urine after 2000mg/kg/day HHT treatment for both sexes. In hematological examinations, we found a significant decreased number of red blood cells (RBC), whereas, an increased the mean corpuscular volume, number of platelets, and rate of reticulocyte (RET) after 2000mg/kg/day HHT treatment of male rats. In male and female rats, 750 and 2000mg/kg/day HHT treatment decreased the number of RBC and increased RET. Histopathological examinations revealed stomach mucosal erosion in female rats (2000mg/kg/day). No-observed-adverse-effect levels were established for 750mg/kg HHT in rats under the conditions of this study. However, other toxicological studies are necessary to evaluate the safety of HHT fully.

Epstein-Barr virus-associated cholestatic hepatitis.

Epstein-Barr virus infection is common in children, usually presenting as infectious mononucleosis, including fever, tonsillitis and lymphadenopathy associated with self-resolving increase in transaminases. Cholestasis is rare in children with only a few cases reported but it was described in up to 55% of the adult population affected. We present a case of a 6-year-old boy with fever, vomiting and choluria. The physical examination showed hepatomegaly and jaundice and was otherwise unremarkable. The laboratory studies revealed increased transaminases (aspartate aminotransferase 97 U/L, alanine aminotransferase 166 U/L), hyperbilirubinaemia (total bilirubin 3.2 mg/dL, direct bilirubin 2.89 mg/dL) and increased γ-glutamyl transpeptidase (114 mg/dL). Urine urobilinogen was increased. The abdominal ultrasound showed hepatomegaly. Epstein-Barr viral capsid antibody IgM was positive and IgG was negative. Serological studies for other viruses were negative. We underline the need to consider Epstein-Barr virus in the cholestatic hepatitis differential diagnosis, in order to avoid unnecessary investigations.

Reliable laboratory urinalysis results using a new standardised urine collection device.

OBJECTIVES: While urine sampling is necessary in the diagnosis of urinary tract infection and electrolyte disturbances, the collection of urine in neonates and non-toilet-trained children is often difficult. A universal urine collection method providing representative urinalyses results is needed. The objective of this study is to evaluate the applicability of the currently used urine collection pads (gauze compresses) and a new urine collection device (Peespot). DESIGN AND METHODS: We tested the reliability of routine (semi-)quantitative urinalysis results with these two different kinds of urine collection methods in a laboratory model. Although important in clinical diagnosis, we did not evaluate the effects on cellular and other components such as casts in the urinary sediment. RESULTS: Most semi-quantitative variables determined by urine stick (pH, blood, protein, leukocytes, nitrite, glucose, ketones, bilirubin and urobilinogen) gave concordant results for both methods compared with native urine. Using the Peespot urine collection device, reliable quantitative results were obtained for calcium, chloride, glucose, magnesium, phosphate, potassium, sodium, osmolality, urea nitrogen and urate compared with native urine. Data were concordant only for chloride, phosphate, glucose, sodium and urea nitrogen by use of gauze compresses. CONCLUSIONS: Urine collection pads are non-invasive methods useful in the collection of urine in non-toilet-trained children. Because of better practical standardisation and more reliable (semi-) quantitative urinalysis results, the Peespot urine collection device is preferred for the collection of urine.

Annotation of the human adult urinary metabolome and metabolite identification using ultra high performance liquid chromatography coupled to a linear quadrupole ion trap-Orbitrap mass spectrometer.

Metabolic profiles of biofluids obtained by atmospheric pressure ionization mass spectrometry-based technologies contain hundreds to thousands of features, most of them remaining unknown or at least not characterized in analytical systems. We report here on the annotation of the human adult urinary metabolome and metabolite identification from electrospray ionization mass spectrometry (ESI-MS)-based metabolomics data sets. Features of biological interest were first of all annotated using the ESI-MS database of the laboratory. They were also grouped, thanks to software tools, and annotated using public databases. Metabolite identification was achieved using two complementary approaches: (i) formal identification by matching chromatographic retention times, mass spectra, and also product ion spectra (if required) of metabolites to be characterized in biological data sets to those of reference compounds and (ii) putative identification from biological data thanks to MS/MS experiments for metabolites not available in our chemical library. By these means, 384 metabolites corresponding to 1484 annotated features (659 in negative ion mode and 825 in positive ion mode) were characterized in human urine samples. Of these metabolites, 192 and 66 were formally and putatively identified, respectively, and 54 are reported in human urine for the first time. These lists of features could be used by other laboratories to annotate their ESI-MS metabolomics data sets.

Acute generalized exanthematous pustulosis and Coombs-positive hemolytic anemia in a child following Loxosceles reclusa envenomation.

Previously reported cases of acute generalized exanthematous pustulosis secondary to brown recluse spider bite have been questioned due to lack of identification of the spider or because of the concomitant administration of antibiotics. We report a 9-year-old boy who arrived at the emergency department with a confirmed Loxosceles reclusa bite to the neck. On the third day of hospitalization, he developed hundreds of monomorphous, sterile pustules, initially in intertriginous areas. The eruption disseminated and was followed by pinpoint desquamation typical for acute generalized exanthematous pustulosis. During this he also developed late onset Coombs-positive hemolytic anemia and systemic loxoscelism. Sphingomyelinase in Loxosceles venom induces the production of interleukin-8 and granulocyte-macrophage colony-stimulating factor, cytokines involved in the pathogenesis of acute generalized exanthematous pustulosis, providing a mechanism by which Loxosceles reclusa bite may trigger acute generalized exanthematous pustulosis. We suggest that this case adds Loxosceles envenomation to the spectrum of agents that can trigger acute generalized exanthematous pustulosis.

Association of UGT1A1 Gly71Arg with urine urobilinogen.

Bilirubin is glucoronized by uridine diphosphate-glucuronosyl transferase 1A1 (UGT1A1) mainly in the liver, and excreted into bile. The conjugated form is metabolized into the unconjugated form, and then into urobilinogen by bacteria in the intestine. Unconjugated bilirubin and urobilinogen are absorbed into the blood stream. The kidney filtrates conjugated bilurubin and urobilinogen into urine. Accordingly, the reduced enzyme activity of UGTIAI may decrease serum conjugated bilirubin levels, resulting in a lower frequency of positive results of urine bilirubin and urobilinogen. This study examined the associations of UGTIAI Gly71Arg (UGTIAI *6) with urine bilirubin and urobilinogen, as well as serum AST, ALT and GGT. Subjects were 5,172 inhabitants 35 to 69 years old who participated in a cohort study in Nagoya from June 2008 to May 2010. Among them, data from 5,151 participants (1,465 males and 3,686 females) were available for analysis. The age-sex-adjusted odds ratio (OR) of ArgArg relative to GlyGly was 1.37 (95% confidence interval (95% CI), 0.55-1.23) for bilirubin, and 1.67 (95% CI, 0.86-3.26) for urobilinogen. Those of ArgArg+ArgGly were 0.87 (95% CI, 0.59-1.27) and 1.50 (95% CI, 1.17-1.94), respectively. AST, ALT and GGT levels had no associations with the genotype. Although the significant association for urobilinogen was contrary to the biological expectation, this study indicated that UGTIA1 Gly71Arg may be a genetic factor of urine urobilinogen.

Evaluation of the iChem® Velocity™ urine chemistry analyzer in a hospital routine laboratory.

BACKGROUND: The novel urine chemistry analyzer iChem Velocity (IRIS Diagnostics) offers improved urinalysis automation options through integration with the well-established iQ200 urine microscopy analyzer. In the course of optimizing the workflow in our hospital routine laboratory, we evaluated the performance of the iChem Velocity. METHODS: A total of 257 random urine samples were analyzed with the iChem Velocity, iQ200, Clinitek Atlas (Siemens Healthcare Diagnostics) and by manual microscopy. RESULTS: Depending on the parameter, 93% (hemoglobin) to 100% (urobilinogen), the iChem Velocity and Clinitek Atlas results agreed within the same rank or within one level of difference. The Clinitek Atlas featured a higher sensitivity for hemoglobin (area under the curve 0.86) and leukocyte esterase (area under the curve 0.85) compared with the iChem Velocity (area under the curve for hemoglobin 0.73, leukocytes 0.78). Imprecision was highest for hemoglobin and leukocytes in a pathological sample pool. While the precision of the Clinitek Atlas for hemoglobin measurements was superior, the iChem Velocity was more precise in analyzing protein and pH. CONCLUSIONS: Through urinalysis automation with the iChem Velocity and iQ200, we achieved a reduction of hands-on time by 89%. The sensitivity of this new system should be further improved through ongoing development.

Abnormal findings on dipstick urinalysis of out-patients with malaria in Abakaliki, Nigeria.

BACKGROUND & OBJECTIVES: Malaria, one of the major health challenges of the tropics affecting about 500 million people, particularly the children and pregnant women have been associated with changes in urine compositions. The present study was undertaken to document the urinary abnormalities in malaria patients based on malaria species and the level of malaria parasitaemia. METHODS: Febrile patients (n = 365) with positive Giemsa - stained blood films for malaria recruited from Outpatient Department of Ebonyi State University Teaching Hospital, Abakaliki participated in the study. Patients were classified into two categories (+ and ++) based on parasite density. Apparently healthy individuals (n = 81), without malaria parasite on both thick and thin films of comparable age and gender acted as control group. Urine sample (10 ml) was collected from each participant and analysed using standard laboratory methods and techniques. RESULTS: Seventy - four (20.3%) of the patients had Plasmodium falciparum malaria. Although all the urine parameters were higher in the malarial patients in comparison to the control, only bilirubinuria and urobilinogenuria were statistically significant (p <0.05). Also, bilirubinuria, urobilinogenuria, haematuria and proteinuria were significantly (p < 0.05) higher in P. falciparum infection than in infections with other malaria species, but only in P. falciparum infection, bilirubinuria and urobilinogenuria were significantly (p < 0.05) higher at higher parasitaemia. CONCLUSION: Even though positive blood film for malaria parasite remains the gold standard for the diagnosis of malaria, urinary abnormalities, such as bilirubinuria, urobilinogenuria, proteinuria and haematuria may aid in identifying patients with severe malaria parasitaemia, especially the falciparum malaria.

Urine markers of kidney disorders and their risk associations in HIV-infected patients attending Nyanza Provincial General Hospital in Kisumu, Western Kenya.

OBJECTIVE: To identify abnormal levels of urine metabolites and cells that serve as markers of existing kidney disorders in ambulatory HIV-infected patients. DESIGN: A cross sectional study. SETTING: Nyanza Provincial General Hospital's patient support centre. SUBJECTS: A total of 593 HIV infected patients were studied. INTERVENTION: Dipstick urinalysis test was used to screen mid stream urine to detect constituents with altered levels. RESULTS: Out of the 593 participants, the urine of 214 (36.1%) had abnormally altered levels of urine constituents, with more females afflicted than males [41.5% vs. 27.8%; OR 1.84 (1.28-2.63), chi2 = 11.08, p = 0.0009]. Urobilinogen was the most common urine metabolite while ketones were least commonly present. More participants had altered levels of leucocytes than erythrocytes in urine. Patients with pyuria were three times more likely to have elevated erythrocytes in their urine as well (chi2 = 34.37, p < 0.0001). Similarly, the risk of having proteinuria was three times higher in patients with pyuria (p < 0.0003, Fisher's test). Patients with erythrocytes in urine also had a threefold likelihood of having proteinuria (P < 0.0003, Fisher's test). Fewer ARV users had abnormal urine markers [15.7% vs 24.3% OR 0.62 (0.41-0.94), chi2 = 5.2, p < 0.05]. CONCLUSION: Metabolites and cellular markers of kidney disorders were prevalent in the urine of HIV patients especially females and those with pronounced immune depletion (CD4 counts equal to or below 500). ARVs use was associated with reduced manifestation of these markers.

Carbon tetrachloride-induced nephrotoxicity in rats: protective role of Digera muricata.

Digera muricata is used in renal disorders in folk medicine. Generation of reactive radicals has been implicated in carbon tetrachloride-induced nephrotoxicity, which are involved in lipid peroxidation, accumulation of dysfunctional proteins, leading to injuries in kidneys. The present study was aimed to evaluate the efficacy of Digera muricata on the kidney function in CCl(4)-induced injuries. CCl(4) treatment (5 ml/kg body wt., i.p. CCl(4):olive oil; 1:9) significantly increased the level of urine creatinine, protein, nitrite, urobilinogen, red blood cells (RBCs), leucocytes count, and levels of blood urea nitrogen (BUN). Level of proteins and DNA fragmentation %, argyrophilic nucleolar organizer regions (AgNORs) count in renal tissues was also significantly increased. Activity of antioxidant enzymes; catalase, peroxidase, superoxide dismutase and reduced glutathione (GSH) were decreased while thiobarbituric acid reactive substances (TBARSs) were increased with CCl(4) treatment. DNA ladder assay was intimately related with the DNA fragmentation assay. Telomerase activity was determined in the CCl(4)-treated renal tissue homogenate. Treatment with n-hexane (HDMP) and methanolic (MDMP) extracts of Digera muricata (200 and 250 mg/kg body wt., oral, respectively) effectively attenuated the alterations in the biochemical markers, telomerase activity was inhibited and confirms the restoration of normalcy and accredits the protective role of Digera muricata against CCl(4)-induced nephrotoxicity.

Acute toxicity evaluation of proliferol: a dose-escalating, placebo-controlled study in rats.

Proliferol is an investigational new drug containing lidocaine hydrochloride 0.25%, dextrose 12.5%, glycerin 12.5%, and phenol 1.0% in aqueous solution. Despite extensive human experience with similar drugs administered by intraligamentous injection for chronic musculoskeletal disorders, little is known concerning preclinical toxicity. The purpose of this study was to assess the acute toxicity of intramuscular Proliferol in 96 (48 male, 48 female) Charles River strain rats, which were randomly assigned to low- (1x), medium- (5x), or high- (10x) dose Proliferol (derived from a human dose of 20 ml on a volume per bodyweight basis), or high-dose saline placebo. Observations included clinical observations, biochemistry, hematology, urinalysis, and full histopathology after 24 h or 14 days. There were no signs of ill health or reaction to treatment, and gait and body temperature were within normal limits. Biochemistry findings at 24 h included elevated aspartate aminotransferase, alanine aminotransferase, and haptoglobin; at 14 days all values were within normal ranges. Urinalysis findings at 24 h included increased urobilinogen and blood in all dose groups compared with placebo. Urine concentrations of phenol and lidocaine were greatest at 2 h and absent at 24 h. Histopathology findings included localized acute inflammatory soft tissue changes at the injection sites at 24 h and skeletal muscle regeneration at 14 days, which were consistent with the anticipated mechanism of action of Proliferol. There was no evidence of systemic toxicity from intramuscular injection of Proliferol in rats at up to 10x the human dose.

Urinalysis.

Urine analysis is an essential component of patient assessment, which is used for screening, diagnosis and planning care. This article discusses specimen collection and reagent strip testing.

Studies of the toxicological potential of tripeptides (L-valyl-L-prolyl-L-proline and L-isoleucyl-L-prolyl-L-proline): V. A 13-week toxicity study of tripeptides-containing casein hydrolysate in male and female rats.

The objective of this multiple-dose toxicity study was to assess the toxicological potential of two tripeptides, L-valyl-L-prolyl-L-proline (VPP) and L-isoleucyl-L-prolyl-L-proline (IPP), when administered once daily for 91 consecutive days to rats. The test article, powdered casein hydrolysate (CH) known to contain 0.6% VPP plus IPP, was prepared using Aspergillus oryzae protease. Prior to administration to the rats by oral gavage, the test article was suspended in sterile water. Groups of 12 male and 12 female Charles River rats were administered once daily doses of 0, 40, 200, or 1000 mg of CH (0, 0.2, 1.2, or 6 mg VPP plus IPP/kg body weight [BW]). Antemortem evaluative parameters included gross observations of behavior and clinical signs; food consumption and body weight gains; ophthalmologic examinations; clinical pathology (hematology, clinical chemistry); and urinalysis. Postmortem parameters included determination of absolute and relative (to fasting body weight) organ weights and histopathological evaluation of approximately 50 organs and tissues from each animal. All rats survived until the scheduled termination of the study and no treatment-related clinical signs were observed. Food consumption was unaffected by administration of CH. All animals gained weight and there were no statistical differences between groups with respect to weight gains. There were no meaningful changes in hematological or coagulation parameters. Mid- and high-dose males (but not females) had slightly (< 2%) increased mean serum chloride concentrations, but because the difference was so small and it was observed in only one sex, the authors considered its association with CH administration to be doubtful. Urinalysis revealed the occasional presence of crystals, leukocytes, and epithelial cells in animals from all experimental groups. Similarly, ophthalmic changes (lenticular clouding) were observed in both control and dosed animals. Mean relative (to body weight) kidney weight was decreased by 8% in low-dose males and mean relative uterus weight was elevated 46% in low-dose females. Absolute organ weights were not affected. Only naturally occurring microscopic changes were observed in all groups and none could be attributed to CH administration. It was concluded that, under the conditions of these experiments, the maximally tolerated dose (MTD) and the no-observable-effect level (NOEL) for powdered CH administered once daily for 13 weeks was greater than 1000 mg/kg BW/day or greater than 6 mg of VPP plus IPP/kg BW/day. There was no evidence of target organ toxicity associated with administration of the tripeptides. This corresponds to an margin of safety (MOS) of 60 based upon current thinking regarding incorporation in food.