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Reading a urinalysis — the kidney-focused guide to blood, protein, leukocytes, casts, specific gravity, and pH, and which findings trigger nephrology follow-up.
Evidence reviewed & updated: 2026-08 — reflects the latest published trials and guidelines.
A urinalysis is the cheapest kidney biopsy-like signal available: protein says filter health, blood and casts point to inflammation, leukocytes flag infection, and specific gravity and pH reveal concentration. Reading it in combination — not finding by finding — is what separates a useful interpretation from alarm.
Protein on a dipstick is graded trace to 4+. Trace or 1+ can be transient (exercise, fever, concentrated urine) — but persistent protein, or proteinuria confirmed by UACR (albumin-to-creatinine ratio), is the single most important kidney-health marker: it's the earliest sign of diabetic, hypertensive, and glomerular kidney disease.
Nephrotic-range protein (heavy) with edema points to glomerular disease (minimal change, FSGS, membranous) — a kidney biopsy conversation.
Hematuria: dipstick 'blood' needs microscopy — intact red cells mean bleeding (stones, infection, glomerulonephritis, cancer in older adults); no cells with a positive dipstick suggests myoglobin or hemoglobin. Casts are the deep signal: red-cell casts are near-diagnostic of glomerulonephritis (urgent), white-cell casts suggest pyelonephritis or interstitial nephritis, and fatty casts mark nephrotic-range proteinuria.
Leukocyte esterase and nitrites usually mean infection — but sterile pyuria (white cells, no bacteria) is a classic clue to drug-induced interstitial nephritis, especially with a rising creatinine.
Specific gravity and osmolality measure the kidney's concentrating ability: fixed low gravity with large urine volumes raises diabetes-insipidus or psychogenic-polydipsia questions; high gravity with low output suggests dehydration.
Urine pH: persistently alkaline urine (with calcium or struvite stones) guides stone prevention — acidification strategies, while uric acid stones form in acidic urine. Context rules: pH, gravity, and chemistries are interpreted together, never alone.
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