Functional Medicine University s Functional Diagnostic Medicine Training Program. Module 1 * Lesson 8. Urinalysis

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1 Functinal Medicine University s Functinal Diagnstic Medicine Training Prgram Mdule 1 * Lessn 8 Urinalysis By Wayne L. Sdan, D.C., D.A.B.C.I., & Rn Grisanti, D.C., D.A.B.C.O., M.S. Limits f Liability & Disclaimer f Warranty We have designed this bk t prvide infrmatin in regard t the subject matter cvered. It is made available with the understanding that the authrs are nt liable fr the miscnceptins r misuse f infrmatin prvided. The purpse f this bk is t educate. It is nt meant t be a cmprehensive surce fr the tpic cvered, and is nt intended as a substitute fr medical diagnsis r treatment, r intended as a substitute fr medical cunseling. Infrmatin cntained in this bk shuld nt be cnstrued as a claim r representatin that any treatment, prcess r interpretatin mentined cnstitutes a cure, palliative, r amelirative. The infrmatin cvered is intended t supplement the practitiner s knwledge f their patient. It shuld be cnsidered as adjunctive and supprt t ther diagnstic medical prcedures. This material cntains elements prtected under Internatinal and Federal Cpyright laws and treaties. Any unauthrized reprint r use f this material is prhibited. Functinal Medicine University; Functinal Diagnstic Medicine Training Prgram/Insider s Guide Md 1 * Lessn 8 : Urinalysis Cpyright 2010 Functinal Medicine University, All Rights Reserved

2 Functinal Medicine University s Functinal Diagnstic Medicine Training Prgram Md 1 * Lessn 8: Urinalysis By Wayne L. Sdan, D.C., D.A.B.C.I., & Rn Grisanti, D.C., D.A.B.C.O., M.S. Cntents End Stage Renal Disease (ESRD): 2005 Statistics 2 Anatmy & Physilgy f the Kidney & Urinary System 2 Urinalysis 3 Types f Urine Specimens 3 Urinary Cllectin Methds 4 Urinalysis: Nrmal Findings 4 Chemical Testing f Urine 8 Sme Causes f Prteinuria 11 Micralbumin 13 Bld 13 Bilirubin 15 Urbilingen 15 Nitrite 16 Leukcyte Esterase 16 Micrscpic examinatin f Urine 17 Kidney Stnes 17 Urinary Tract Infectins: Integrative Therapy 20 References 22 1

3 Functinal Medicine University s Functinal Diagnstic Medicine Training Prgram Md 1 * Lessn 8: Urinalysis By Wayne L. Sdan, D.C., D.A.B.C.I., & Rn Grisanti, D.C., D.A.B.C.O., M.S. End Stage Renal Disease (ESRD) : 2005 Statistics 485,012 US residents were under treatment as f the end f the calendar year resulting frm the primary diseases: Diabetes 179,157 Hypertensin 117,438 Glmerulnephritis 78,345 Cystic kidney 22,458 All ther 87,614 Mrtality: deaths per 1000 (85,750 deaths) Cst fr ESRD prgram: 32 billin in public & private spending Anatmy & Physilgy f the Kidney & Urinary System Majr functins Remval f metablic waste & txic substances Regulatin f vlume & cmpsitin f bdy fluids by re-absrptin & secretin Maintenance f acid-base balance Maintenance f bld pressure & erythrpiesis Substances prduced Erythrpietin: frmatin f RBC. Released when bld xygen falls 1,25 dihydrxychlecalciferl Renin: catalyzes the cnversin f angitensingen (a prtein made in the liver) int angitensin I, which is cnverted t angitensin II by ACE in the lungs Innervatin f the Kidneys Sympathetic T 10, T 11, T 12, L 1 Parasympathetic Vagus nerve Hypgastric nerve S 2 S 4 Afferent fibers Vagus nerve T 10, T 11, T 12 2

4 Functinal Medicine University s Functinal Diagnstic Medicine Training Prgram Md 1 * Lessn 8: Urinalysis By Wayne L. Sdan, D.C., D.A.B.C.I., & Rn Grisanti, D.C., D.A.B.C.O., M.S. Urinalysis Prvides infrmatin abut Majr metablic functins Renal disease First indicatin f asymptmatic diabetes mellitus and sme liver diseases Types f Urine Specimens First mrning urine specimen A.M. Urine is cncentrated testing is mre apt t detect psitive finding.(prteins, nitrites) Empty bladder befre bed the night befre. Increases accuracy f patient s 24-hurs urine If specimen will nt arrive at the lab within 2 hurs f cllectin, it must be preserved (refrigerated). Randm Urine Specimen Used in rutine screening (i.e. drug testing) Substance tested has n diurnal variatin Timed Urine Cllectin Specimen Used fr substances with variable excretins ver 24 hur perid ( e.g. hrmnes, prteins & electrlytes) Duble Vided Specimen Used t mnitr urine glucse and ketnes Bladder is emptied; secnd vid is cllected shrtly thereafter 3

5 Functinal Medicine University s Functinal Diagnstic Medicine Training Prgram Md 1 * Lessn 8: Urinalysis By Wayne L. Sdan, D.C., D.A.B.C.I., & Rn Grisanti, D.C., D.A.B.C.O., M.S. Urinary Cllectin Methds Rutine vid specimen N preparatin necessary Cllectin time can be randm r first mrning urine Mid-stream and clean-catch specimen fr culture & sensitivity Clean urinary meatus Midstream cllectin in sterile cntainer 24 Hur Urine Cllectin Discard 1 st urine specimen and nte the time Cllect urine fr 24 hurs Nte: It is imprtant t check lab manuals (Quest, LabCrp, etc) fr prper cllectin prcedure and type f urine specimen fr details n cllectin methds. And be sure that yu are CLIA cmpliant! Urinalysis: Nrmal Findings Appearance: clear Clr: Amber yellw Odr: armatic ph: average 6.0 Prtein: 0-8 mg/dl mg/24 at rest <250 mg/24 (during exercise) Specific gravity: (usually ) Leukcyte esterase: negative Nitrites: nne Ketnes: nne Bilirubin: nne Urbilingen: Erlich unit/ml Crystals: nne Casts: nne Glucse: nne 4

6 Functinal Medicine University s Functinal Diagnstic Medicine Training Prgram Md 1 * Lessn 8: Urinalysis By Wayne L. Sdan, D.C., D.A.B.C.I., & Rn Grisanti, D.C., D.A.B.C.O., M.S. Urinalysis: Nrmal Findings (cn t) White bld cells: WBC casts: RBC s: RBC casts: 0-4 per high-pwer field nne 2 hpf nne Physical exam f urine Appearance Nrmal : Clear t smewhat hazy Hazy r cludy Clr Amrphus, phsphates, r urates WBC s RBC s, epithelial cells, bacteria Fat (milky appearance) Mucus Nrmal: pale yellw t amber due t the pigment urchrme (prduct f bilirubin metablism) Abnrmal: Pathlgical cnditins Ingestin f certain fds (B-vitamins, beets) * Medicines * Because urine clr may be affected by the use f varius types f drugs, (i.e., antibitics, laxatives, muscle relaxants, etc.), and sme vitamins (vitamin B) and supplements, it is imprtant t determine if the patient is taking any f these when perfrming urine analysis. Clrless: Large fluid intake Diabetes insipidus Untreated diabetes mellitus 5

7 Functinal Medicine University s Functinal Diagnstic Medicine Training Prgram Md 1 * Lessn 8: Urinalysis By Wayne L. Sdan, D.C., D.A.B.C.I., & Rn Grisanti, D.C., D.A.B.C.O., M.S. Physical exam f urine Clr (cn t) Orange: Drugs Bile Diet Uric acid crystals Brwnish/greenish yellw Bilirubin Drugs Indican Pseudmnas infectins Red: Bld Prphyria Drugs Diet (beets) Brwn: Bld Bilirubin Urbilingen Indican Diet (rhubarb) Greenish: Pseudmnas infectin Fd dyes Medicatins 6

8 Functinal Medicine University s Functinal Diagnstic Medicine Training Prgram Md 1 * Lessn 8: Urinalysis By Wayne L. Sdan, D.C., D.A.B.C.I., & Rn Grisanti, D.C., D.A.B.C.O., M.S. Vlume Influencing factrs Fluid intake Nnrenal fluid lss Variatin in ADH secretins The bdy s necessity t excrete large amunts f disslved slids (salts, glucse) Plyuria: increased urine vlume Diabetes mellitus Diabetes insipidus (depressed ADH) Oliguria: decreased vlume Dehydratin, vmiting, severe burns Nrmal vlume fr 24-hr urine sample: ml Clinical Significance Lw vlume Dehydratin Renal disease Urinary tract bstructin High vlume Diuretics Diabetes mellitus Diabetes insipidus 7

9 Functinal Medicine University s Functinal Diagnstic Medicine Training Prgram Md 1 * Lessn 8: Urinalysis By Wayne L. Sdan, D.C., D.A.B.C.I., & Rn Grisanti, D.C., D.A.B.C.O., M.S. Urine Odr Nrmal: armatic dr Sweet: diabetic ketacidsis Ful smelling: UTI Fecal Odr: entervesical fistula Chemical Testing f Urine Specific Gravity density f urine Measures the weight f urine cmpared t that f water (SG f water is 1.000) Matter in the urine give it weight Used t evaluate the cncentrating and excretry effectiveness f the kidneys Must be interpreted in light f the presence r absence f glycsuria r prteinuria, and hydratin status Usual nrmal range: Optimal range: Clinical Significance Lw Diabetes insipidus (decreased prductin ADH) Glmerulnephritis (inability t cnc. urine) Pyelnephritis High Adrenal insufficiency Hepatic disease CHF Dehydratin Diabetes mellitus 8

10 Functinal Medicine University s Functinal Diagnstic Medicine Training Prgram Md 1 * Lessn 8: Urinalysis By Wayne L. Sdan, D.C., D.A.B.C.I., & Rn Grisanti, D.C., D.A.B.C.O., M.S. ph Measure f hydrgen in cncentratin Indicates the acid-base balance Reflects the wrk f the kidneys in maintaining nrmal ph hmestasis Range variable: Alkaline ph Alkemia UTI Diet high in citrus r vegetables Acid ph Diabetes mellitus Metablic r respiratry acidsis Starvatin Dehydratin Diet high in meat prducts r cranberries COPD Urine ph is useful in identifying crystals and determining the predispsitin t frm a given type f stne. Acid urine Xanthine, cysteine, uric acid and calcium xalate- t treat r prevent, keep the urine alkaline Alkaline urine Calcium carbnate, calcium phsphate, magnesium phsphate t treat r prevent, keep urine acidic. Glucse (Glycsuria) Nrmal value: negative Occurs when bld glucse level exceeds the re-absrptin capacity f the renal tubules. Glucse is nt excreted by the kidney unless bld levels exceed 180 mg/dl. 9

11 Functinal Medicine University s Functinal Diagnstic Medicine Training Prgram Md 1 * Lessn 8: Urinalysis By Wayne L. Sdan, D.C., D.A.B.C.I., & Rn Grisanti, D.C., D.A.B.C.O., M.S. Glucse (Glycsuria) (cn t) Nt always indicative f diabetes. May als ccur in diseases that affect the renal tubules r in genetic disrders. Glycsuria with high bld sugar Diabetes mellitus (chief cause f glycsuria) Infectins Obesity Glycsuria withut a high bld sugar Renal glycsuria Fancni syndrme (transprt defect f prximal tubules) genetic defect Inflammatry renal disease Nephrtxic chemicals (mercury, lead, cadmium) Pregnancy Ketnes Nrmal value: negative Intermediary prducts f fat metablism Inadequacy f carbhydrates indicative f prblem with metablism r malabsrptin which causes an increase in fat metablism. Usually assciated with prly cntrlled diabetes Assciated with alchlism, fasting, starvatin, high prtein diets. Indicated in acute febrile illnesses, particularly infants and children Prtein Reference range: negative t trace randm sample: 0-8 mg/dl 24 hur sample may cntain up t 35 mg f albumin and up t 50 mg f ther prteins (i.e. immunglbulin, glbulins, Tamms-Hrsfall prtein) 10

12 Functinal Medicine University s Functinal Diagnstic Medicine Training Prgram Md 1 * Lessn 8: Urinalysis By Wayne L. Sdan, D.C., D.A.B.C.I., & Rn Grisanti, D.C., D.A.B.C.O., M.S. Prtein (cn t) Unless abnrmally high, nrmal amunts will nt be detected n the urine reagent strip in a randm specimen (fr truer reading, a Micralbumin test r cncentrated urine test is recmmended) Tends t increase with age, exercise and standing psture. Prteinuria has been defined as 24 hur urine prtein excretin >150 mg/24 hurs. Infants and children >100 mg/24 hurs. Even with nrmal kidney functin, sme prteins will appear in the urine if the levels f prtein in the bld becme high. Is a sensitive marker f kidney functin and renal disease Frms the basic matrix f urinary casts. Functinal prteinuria refers t prtein excretin in assciatin with fever, excessive exercise r emtinal stress. Sme Causes f Prteinuria Prerenal prteinuria Cngestive heart failure Orthstatic prteinuria Transient, assciated with febrile illness, surgery, anemia, hyperthyridism, strke, exercise, seizures Bence Jnes prteinuria assciated with myelma, Waldenstrm macrglbulinemia, amylidsis (light chain prteinuria) 11

13 Functinal Medicine University s Functinal Diagnstic Medicine Training Prgram Md 1 * Lessn 8: Urinalysis By Wayne L. Sdan, D.C., D.A.B.C.I., & Rn Grisanti, D.C., D.A.B.C.O., M.S. Renal prteinuria Renvascular hypertensin Malignant hypertensin f any cause Membranus nephrpathy & prliferative glmerulnephritis Chrnic pyelnephritis Plycystic disease Diabetic nephrpathy Amylidsis Lupus erythematsus (SLE) Gdpasture s syndrme Renal vein thrmbsis Minimal change nephrpathy HIV nephrpathy Alprt syndrme Preeclampsia Glmerular Prteinuria > 3.5 g/24 hr usually Reflects a glmerular lesin (in children > 1.0 g/m 2 /day) Fancni Syndrme Wilsn disease Heavy metal pisning: lead mercury cadmium Galactsemia Tubular Usually <1 g/24h Bacterial pyelnephritis Uric acid, urate, r calcium depsitin Idisyncratic drug reactin: methicillin phenindine sulfnamides phenytin thers Interstitial diseases generally reflected as tubular defects r mixed tubular interstitial Interstitial 12

14 Pstrenal prteinuria Functinal Medicine University s Functinal Diagnstic Medicine Training Prgram Md 1 * Lessn 8: Urinalysis By Wayne L. Sdan, D.C., D.A.B.C.I., & Rn Grisanti, D.C., D.A.B.C.O., M.S. Tumrs f the bladder r renal pelvis < 1 g/24 h, IgM excretin significant marker, amunt f prteinuria related t size and spread f tumr Cystitis, severe Interfering factrs Drugs can increase prtein in the urine. Radipaque cntrast media administered within 3 days may cause false psitive. Urine cntaminated with prstate r vaginal secretins High prtein diet Severe emtinal stress Nte: Increased prtein and leukcytes usually indicates a UTI. Micralbumin Nrmal Range: < 20 mg/l MA/Creatinine Rati: 0-30 mg/g Micralbuminuria refers t an albumin cncentratin in the urine that is greater than nrmal, but is nt detectable with rutine prtein testing. MA is the earliest indicatr fr develpment f diabetic cmplicatins (nephrpathy, CVD, and hypertensin). Can identify diabetic nephrpathy 5 years befre rutine prtein urine tests. Micral urine test strip best perfrmed with 1 st mrning urine vid. Bld Reference Range: Negative Micrscpy: up t 2-3 RBC/hpf Psitive dipstick indicates hematuria, hemglbinuria, r myglbinuria. If psitive in dipstick, micrscpy is indicated. 20% f patients lder than 40 years with asymptmatic hematuria have significant urlgic lesins, f which half are malignant. Bld may be present as intact cells (nn-hemlyzed) r as free hemglbin (hemlyzed r ruptured RBC). Hemglbinuria withut hematuria implies intravascular hemlysis, while hematuria suggests a bleeding surce in the urinary tract. 13

15 Functinal Medicine University s Functinal Diagnstic Medicine Training Prgram Md 1 * Lessn 8: Urinalysis By Wayne L. Sdan, D.C., D.A.B.C.I., & Rn Grisanti, D.C., D.A.B.C.O., M.S. Causes f hemglbinuria Hemglbinuria with intact red cells in sediment. N casts present. Pssible causes: Menstruatin Vigrus exercise Trauma t urinary tract Cystitis Calculi Kidney tumrs Malignant hypertensin Sickle cell (disease r trait) Hemglbinuria with intact red cells in sediment. Red cell r granular casts nted. Prteinuria present. Pssible causes: Acute glmerulnephritis Chrnic glmerulnephritis Lupus nephritis Plyarteritis Gdpasture s syndrme Allergic nephrpathy Hemglbinuria with n intact red cells in sediment. Pssible causes: Delayed examinatin (esp. if dilute urine) Hemlytic disrders (immune and nn-immune) Presence f myglbin Serum creatinine kinase levels high Oxidative stress 14

16 Functinal Medicine University s Functinal Diagnstic Medicine Training Prgram Md 1 * Lessn 8: Urinalysis By Wayne L. Sdan, D.C., D.A.B.C.I., & Rn Grisanti, D.C., D.A.B.C.O., M.S. Bilirubin Nrmal values: negative Is a majr cnstituent f bile. If excretin is inhibited, cnjugated (direct) hyperbilirubinemia will result. Bilirubin in the urine suggests disease affecting bilirubin metablism after cnjugatin r defects in excretin. Only cnjugated bilirubin is passed int the urine, thus a psitive reactin is evidence f hepatcellular r biliary disease. Clinical implicatins f elevated urine bilirubin Extrahepatic duct bstructin (gallstnes, inflammatin, tumr) Infectins r hepattxic agents (liver cells are unable t excrete all f the direct bilirubin) Urbilingen Nte: Bilirubin is very light sensitive. It will disappear frm urine n standing; specimen shuld be prcessed immediately. Nrmal value: trace r < 2 Ehrlich units/dl (1 EU = 1 mg f urbilingen) One f the earliest signs f acute liver damage Direct bilirubin is excreted frm liver cells int the bile, then int the intestinal tract thrugh the bile duct. It is cnverted by bacterial actin t urbilingen. Abut 50% f the urbilingen is reabsrbed int the prtal circulatin. Urbilingen is increased by any cnditin that causes an increase in the prductin f bilirubin and by any disease that prevents the liver frm nrmally remving the reabsrbed urbilingen frm prtal circulatin. Urbilingen is decreased r absent when nrmal amunts f bilirubin are nt excreted in the intestinal tract. 15

17 Functinal Medicine University s Functinal Diagnstic Medicine Training Prgram Md 1 * Lessn 8: Urinalysis By Wayne L. Sdan, D.C., D.A.B.C.I., & Rn Grisanti, D.C., D.A.B.C.O., M.S. Differential Diagnsis Using Urine Bilirubin and Urbilingen Tests Type f Jaundice Urine Bilirubin Urine Urbilingen Nrmal trace Hepatcellular jaundice (eg, hepatitis, chemical, r drug injury) Biliary bstructin (extrahepatic & intraphepatic); bstructive jaundice Hemlytic jaundice 0 0 = absent; present 0 Nitrite Nrmal Value: negative Screening test fr UTI s (sme UTI s are asymptmatic) Many bacteria prduce an enzyme called Reductase, which can reduce urinary nitrates t nitrites. A psitive result indicates the need fr urine culture Leukcyte Esterase Nrmal Value: negative Indirect test fr the detectin f bacteremia Will detect either intact r lysed WBC Leukcyte esterase is unacceptable as a screen unless cmbined with nitrite testing. Leukcyte esterase, even cmbined with nitrite shuld nt replace micrscpy and culture in symptmatic patients. 16

18 Micrscpic examinatin f Urine Types f sediment As ne authr puts it: Cells Casts Crystals Critters Organized bilgical part Functinal Medicine University s Functinal Diagnstic Medicine Training Prgram Md 1 * Lessn 8: Urinalysis By Wayne L. Sdan, D.C., D.A.B.C.I., & Rn Grisanti, D.C., D.A.B.C.O., M.S. RBC WBC Casts Epithelial cells Bacteria, parasites, yeast & fungi Unrganized Crystals Amrphus crystalline matter Kidney Stnes Calcium Cntaining Stnes: Causes SAD (Standard American Diet) Lw in fiber High in refined carbhydrates, alchl cnsumptin, animal prtein, fat High intake f high-calcium, lw-magnesium, vitamin D-enriched milk prducts. Obesity and insulin insensitivity Sugar: increase in urinary calcium xalate 17

19 Functinal Medicine University s Functinal Diagnstic Medicine Training Prgram Md 1 * Lessn 8: Urinalysis By Wayne L. Sdan, D.C., D.A.B.C.I., & Rn Grisanti, D.C., D.A.B.C.O., M.S. Kidney Stnes (Calcium Cntaining Stnes: Causes) cn t Magnesium deficiency Magnesium increases the slubility f calcium xalate and inhibits bth calcium phsphate and calcium xalate stne frmatin. Supplementing magnesium shwn t prevent recurrences f kidney stnes. Vitamin B 6 deficiency Vitamin B 6 reduces the prductin f excretin f xalates. Kidney Stnes : Preventive Measures Fr all types f kidney stnes Maintain ideal weight Drink at least 3L f nn-alchlic, (preferably purified water) fluid daily Exercise regularly Minimize intake f sugar, refined carbhydrates, and alchl Cnsume a diet in green leafy vegetables, nutrient-rich, whle fds Kidney Stnes : Treatment Calcium Stnes Diet Increase intake f fiber, cmplex carbhydrates, and green leafy vegetables. Increase intake f high magnesium-t-calcium rati fds barley, bran, crn, buckwheat, rye, sy, ats, brwn rice, avcad, banana, cashew, ccnut, peanuts, sesame seeds, lima beans, ptat If stnes are xalate, reduce xalate-cntaining fds black tea, cca, spinach, beet leaves, rhubarb, parsley, cranberries, and nuts Limit intake f prducts made with milk 18

20 Functinal Medicine University s Functinal Diagnstic Medicine Training Prgram Md 1 * Lessn 8: Urinalysis By Wayne L. Sdan, D.C., D.A.B.C.I., & Rn Grisanti, D.C., D.A.B.C.O., M.S. Kidney Stnes : Treatment (cn t) Uric Acid Stnes Diet Decrease cnsumptin f purine-rich fds Organ meats, meats, shellfish, yeast (brewer s and bakers), herring, sardines, mackerel, and anchvies Decrease cnsumptin f fds with mderate levels f purines Dried legumes, spinach, asparagus, fish, pultry, and mushrms Nutritinal Supplements Calcium Stnes Vitamin B 6 : 25 mg q.d. Magnesium 600 mg q.d. increases the slubility f calcium xalate Calcium citrate r malate: mg q.d. Citrate bund t magnesium r ptassium: mg q.d. citrate has the ability t reduce urinary saturatin f calcium xalate and calcium phsphate Uric Acid Stnes Flic acid 5 mg q.d. flic acid inhibits xanthine xidase, the enzyme respnsible fr the prductin f uric acid 19

21 Functinal Medicine University s Functinal Diagnstic Medicine Training Prgram Md 1 * Lessn 8: Urinalysis By Wayne L. Sdan, D.C., D.A.B.C.I., & Rn Grisanti, D.C., D.A.B.C.O., M.S. Urinary Tract Infectins : Integrative Therapy Nutritin Remval f Bladder Irritants Dietary bladder irritants such as caffeine, refined sugar, white flur, alchl, and nictine shuld be avided. Increase cnsumptin f Garlic Onin Fluids Flaxseed Cntains mucilage, which sthes the lining f the urinary tract. Dsage: 1-3 Tablespns f grund fresh flaxseed taken with fd. Vitamin C Has an acidifying effect n the urine. Prbitics Taken after meals t prmte digestive tract health Btanicals Cranberry Recmmended fr its anti-adherence prperties Dsage: sixteen unces f unsweetened pure (nt ccktail ) juice a day, diluted with water, 1-2 capsules f dried cranberry pwder, 2 t 4 times per day. 20

22 Functinal Medicine University s Functinal Diagnstic Medicine Training Prgram Md 1 * Lessn 8: Urinalysis By Wayne L. Sdan, D.C., D.A.B.C.I., & Rn Grisanti, D.C., D.A.B.C.O., M.S. Urinary Tract Infectins : Integrative Therapy (cn t) Uva Ursi Key cnstituents are arbutin and hydrquinne. Arbutin has demnstrated antimicrbial activity against gram-psitive and gram-negative bacteria, including E.cli and is absrbed frm the gastrintestinal tract and hydrlyzed t hydrquinne in alkaline urine. Gldenseal Dsage: 3 g f the dried herb r mg f hydrquinne derivatives 4 times a day. Cntraindicatins This herb shuld nt be used during pregnancy and lactatin r in children yunger than 12 years. Because f the large amunt f tannins present in this herb, it is nt recmmended fr use beynd a 1-week perid and nt mre than five times a year. Prlnged tannin expsure may lead t gastrintestinal intlerance and hepattxicity. Berberine is ne f the alkalids in gldenseal and is believed t have antibacterial prperties against gram-psitive and gram-negative bacteria, including E. cli. Dsage: recmmend a standardized extract with berberine as the main cmpnent, 2 4 g f dried rt r slid extract (4:1, r 8% - 12% alkalid cntent) mg daily. Precautins: avid gldenseal in pregnancy Nte: It is highly recmmended that yu btain PDR (Physician Desk Reference) Guides fr Herbal Medicines, Prescriptin and Nn-Prescriptin Drugs, and Dietary Supplements. 21

23 Functinal Medicine University s Functinal Diagnstic Medicine Training Prgram Md 1 * Lessn 8: Urinalysis By Wayne L. Sdan, D.C., D.A.B.C.I., & Rn Grisanti, D.C., D.A.B.C.O., M.S. References 1. Labratry Test Handbk; 5 th Editin; David S. Jacbs, M.D., Wayne R. DeMtt, M.D., Dwight K. Oxley, M.D. 2. Integrative Medicine; 1 st Editin; David Rakel, M.D. 3. Msby s Manual f Diagnstic and Labratry Tests; 3 rd Editin; Pagana/Pagana 4. Atlas f Human Anatmy; 2 nd Editin; Frank H. Netter, M.D. 5. Labratry Evaluatins fr Integrative & Functinal Medicine; 2 nd Editin; Richard S. Lrd, Ph.D, J. Alexander Bralley, Ph.D. 6. Natural Medicine Instructins fr Patients; 1 st Editin; Lara U. Pizzrn, MA(Div), MA(Lit), LMT, Jseph E. Pizzrn, Jr., ND, Michael T. Murray, ND 7. CMDT 2006; Current Medical Diagnsis & Treatment; 45 th Editin; Lawrence M. Tierney, Jr., M.D., Stephen J. McPhee, M.D., Maxine A Papadakis, M.D. 8. NIH; Natinal Institutes f Health; Kidney and Urlgic Disease Statistics fr the United States 22