A few years ago, I was engaged by a defense attorney to write an amicus curiae brief on behalf of a serviceman who was appealing his dishonorable discharge that had been based on presumed failure to provide a urine specimen for drug testing. In the U.S. Department of Defense drug testing program, the appearance of tampering is the same as refusing to provide a urine specimen. The urine specimen had a creatinine concentration <5 mg/dL (< 0.44 mmol/L), which did not meet the minimum creatinine concentration criteria for an acceptable specimen, and was presumed diluted or substituted. At the time the urine specimen was collected, the serviceman was aboard an aircraft carrier in the Persian Sea, and the specimen was shipped under ambient temperatures back to the U.S. for testing, the transit requiring several days. The collection was observed. I argued in the brief that contamination of urine specimens with ubiquitous creatinine-consuming bacteria (e.g., creatininase from Pseudomonas, or creatinine deaminase from Corynebacterium) and consequently low urine creatinine concentration was a possibility in this case.

 

A few weeks later, I was told my argument had been dismissed, and the decision of the lower court was upheld. The government expert had successfully argued that creatinine “has a melting point of 300 degrees Celsius, and therefore cannot decompose below that temperature.”

 

Roger

 

Roger L. Bertholf, PhD

Medical Director of Clinical Chemistry

Houston Methodist Hospital

Professor of Clinical Pathology and Laboratory Medicine

Wiell Cornell Medicine

 

 

Dear all,

 

Here is an update on the unusually low urine creatinine case which I posted a couple of months ago.

 

Firstly we arranged for a repeat sample and the very low urine creatinine was confirmed by mass spectrometry.

 

Secondly I then arranged for the patient to attend the laboratory to provide us with a very fresh sample; which we then went on to culture and also measured the urine creatinine (enzymatic assay) at regular intervals over a period of 48 hours (urine sample was stored at room temp).

 

Results:-

 

The freshly voided urine had a very strong odour and showed a heavy mixed bacterial growth on culture (> 10e8 orgs per ml), and also had raised WBC & RBC.

The urine creatinine results are attached and show a linear decrease in concentration with time which is almost certainly due to bacterial contamination.

 

I have been in this job for more years than I care to mention but have never come across anything quite like this before; although there are literature similar case reports.

………. but this does beg the question as to how often less dramatic effects might be occurring in our samples, on a day to day basis and compromising our urine creatinine concentrations.

 

Thank you for all your interest in this case.

 

Kind regards

 

Ian

 

Acknowledgment: Thank you to Lynda Bartlett for arranging for the urine creatinine analysis

 

 

 

 

 

The urine creatinine is probably truly low for some reason as both Jaffe & enzymatic couldn’t record a result.

 

Is the urine from an ileal urinary diversion? This could lead to contamination with creatinine splitting bacteria?

Similarly, is there UTI due to such bacteria.

Is there microbiology study of such urine?

 

Experiment: do dilution studies of serum creatinine using the patient’s urine as diluent, you may need to keep the diluted samples overnight before analysis.

 

Regards,

 

 

Mohammad

 

 

 

 

It could well be and I have already received an offer from a mass spectrometrist to check creatinine and creatine!

 

The mailbase is just great!!

 

Thank you for all your interest!

 

Ian

 

 

Is it worth seeing if you can get creatine measured?

 

 

Yes the urine is recent. We have had 4 such samples- all with low urine creat over the past year. I suspect it is assay interference – which could be a contaminant at sampling – I am pursuing this angle at present.

 

She is type 2 diabetic and had her Alb/Creat ratio checked.

 

Ian

 

 

Apology Ian! Is the urine test recent?  How recent and why it was requested in the first place?

 

 

Hi Ali

 

I don’t know what her urine volume is and I don’t know what her height is.

 

Her last bloods were done in June last year:-

 

Sodium = 146 mmol/L

Potassium = 4.0 mmol/L

Urea = 6.2 mmol/L

 

Osmo and bicarb were not requested.

 

Thank you for your interest

 

Kind regards

 

Ian

 

 

Apology meant likelihood of SIADH??

 

 

Very concentrated urine! What is her 24 hour urine volume?? What is her serum urea/Na/K/HCO3/Osmolal and height please? What is the likelihood of DI???

 

Kind regards

Ali

 

 

Kind Regards

ALi

Dr Ali Al-bahrani  MBCh.B MSc.Chem Path.  EuClin.chem. CSci. FRCPath.
Lead Pathologist for Blood Sciences
Consultant Chemical Pathologist and metabolic medicine and HOD of Blood Sciences
St Mary's Hospital
Newport
Isle of Wight
PO30 5TG
United Kingdom
Te: 01983 534859/534917

 

 

 

 

 

 

Dear collective,

 

We have a very unusual urine creatinine result - which has been confirmed by both enzymatic and Jaffe assays, and confirmed on 3 previous occasions.

 

The female patient is a reasonably well 72 years old. She is not taking any medication of note (and not taking any “internet potions”), her BMI is 40 and she does not have a myopathy. Her serum creatinine (enzymatic assay) is 76umol/L.

 

Urine results are as follows:-

 

Urine sodium = 173 mmol/L

Urine potassium = 34 mmol/L

Urine urea = 292 mmol/L

Urine creatinine = <0.1 mmol/L

Urine osmolality = 781 mosm/kg.

 

Any ideas?

 

Kind regards

 

Ian Barlow

Consultant Biochemist

Chemical Pathology Clinical Director

 

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