**4. Discussions**

## *4.1. Awareness and Utilization of Blue Carbon Ecosystems*

The residents of Busuanga have a high recognition of mangroves because of their tangible benefits. Field observations and oral accounts documented that locals collect fish and shells in mangrove areas when their financial capacity to buy food is limited. This scenario is very common among coastal communities in the Philippines. Some locals are getting paid for assisting recreational activities such as firefly watching and paddling in mangrove areas. Moreover, coastal residents have first-hand experience with the protection services of mangroves when the super typhoon Haiyan hit the country in 2013. Ref. [33] have documented that mangrove services are highly recognized by the people when they are directly benefited by them; the more services they can get or observe, the higher they value the ecosystem. As for seagrass awareness, provisioning services are well acknowledged by the locals compared to other services (i.e., regulating, cultural). Unlike mangroves, seagrass ecosystem services are not well streamlined in coastal programs or often grouped with other ecosystems because the priorities for research and development activities are usually directed towards coastal resources with immediate economic impacts [34,55]. However, C3 Philippines, an NGO, is changing this trend. This group has already conducted several seagrass awareness campaigns (including blue carbon functions) on the island as part of their thrusts on the Dugong conservation program (program coordinator of C3 Philippines, personal communication, 19 July 2019).

The utilization frequency of BCE services in Busuanga is generally low despite residents' proximity to these resources (see Figure 3). Using correlation and multiple regressions, awareness level and sociodemographic characteristics of the locals were explored to determine whether these have an influence or none on their utilization behaviors (see Supplementary Materials). This study shows that the effect of social profile on the local's utilization behavior is inconclusive. As pointed out by [56], socio-demographics as predictor variables do not always influence their behavior. However, to some degree, the occupation of the residents influences their utilization behavior (as hypothesized); fishers are more active in using the BCEs services meanwhile others (i.e., farmers, employed individuals) are less active. Fishing in BCEs, though, is low in Busuanga since they utilize coral reefs more [57]. Harvesting mangroves for charcoal-making has reduced due to strict implementation of local ordinances and the establishment of marine protected areas on the island [57]. Moreover, cultural services offered by the BCEs are not used since most of the tourism-related activities on the island feature other ecosystems like coral reefs, beaches, and small islands.

The awareness level of BCE services in Karimunjawa reflects an overall low trend that agrees with previous perception studies on the island (i.e., [58,59]). Provisioning benefits are poorly received while cultural functions of BCEs are well perceived (see Figure 2). Regulating services like the blue carbon functions are generally unrecognized, while coastal protection and natural buffer services are acknowledged by the locals. To date, there are now different blue carbon opportunities in Indonesia [29], however, blue carbon related works are mainly focused on the carbon potential of BCEs (i.e., [60]) rather than on BCE awareness and capacity building among coastal communities.

Looking at the possible factors affecting their perceptions, the occupation of the locals is negatively associated with their awareness and utilization behaviors. Based on the 2017 population of Karimunjawa, fishers comprise 47.0% of the residents [45] thus, it is expected to document high utilization frequency (positive correlation). However, this study shows low utilization frequency (negative correlation); 59.6% to 68.1% of the locals do not perform fishing/gleaning activities. This may be due to the smaller number of fishers (21.3%) in the respondents and more (34.0%) salaried individuals. Accessibility to BCEs could potentially influence resident's usage rate [58]; however, despite the proximity of the respondents to BCEs, utilization yields are still low. This is because most of the fishers on the island are pelagic fishers [45]. Another factor that could influence their utilization is the level of awareness. Similar to Busuanga, the awareness and utilization in Karimunjawa correlate with each other. Residents who utilized the services (i.e., food source) are typically those who only recognized the benefits of BCEs. The work of [59] on the island also captured fewer fishing activities in mangroves because of their low awareness while gleaning activities in seagrass beds depend on the awareness of the abundance of associated organisms [58]. Interestingly, activities related to cultural activities are also low (see Figure 3) despite Karimunjawa becoming a popular tourism site [59].


**Author details**

Ersin Muhafiz Kafkas University Faculty of Medicine, Kars, Turkey

\*Address all correspondence to<EMAIL_ADDRESS>
© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


temperature water were compared with those of body temperature with one-sample T-test. We found that the "naloxone" levels of room temperature water (M = 836.75, SD = 326.50) were not significantly different from those with body temperature water (M = 909.25, SD = 181.50); t(6) = .388, p = .711). Thus, the temperature difference did not affect "naloxone" levels. Finally, when the "naloxone" levels of body temperature purified water, body temperature 10% urine and body temperature pure urine were compared by a one-way ANOVA, there was no statistical difference (F(2, 9) = [.690], p = .526). Thus, the urine concentration difference did not affect "naloxone" levels. These results indicate that temperature and concentration of urine samples did not affects "naloxone" levels.

#### **4. Discussion**

#### **4.1 Clinical effects of sublingual naloxone**

This study demonstrated that high levels of "naloxone" were found in adulterated urine samples from individuals who were not taking any medications. High levels of "naloxone" were also detected in the purified water samples when buprenorphine/ naloxone film was dipped into the samples. Thus, these results and those in the previous studies on urine "naloxone" levels suggest that "naloxone" can be detected in adulterated urine samples both from those who are not on buprenorphine/naloxone and those who are on buprenorphine/naloxone [15, 20]. This information can lead to the speculation that "naloxone" detected in urine samples can be mere dissolvents of some fraction of naloxone instead of metabolites, and consequently imply a possibility that "naloxone" in urine samples from the patients taking buprenorphine/ naloxone films were the mere dissolvents of some naloxone in the urinary system, considering naloxone's low bioavailability and extensive first-pass metabolism. Unfortunately, we were unable to distinguish between "naloxone" in urine that has been excreted by nephrons after it was absorbed and metabolized versus some fractions of "naloxone" that have been only dissolved in the system.

The clinical effects of sublingual naloxone on healthy patients have been controversial. For example, Nasser, et al. conducted a research study, in which 43 participants received one single sublingual tablet of brand name Suboxone (buprenorphine/ naloxone 2 mg/0.5 mg) and their plasma "naloxone" levels in their blood samples were monitored for up to 168 hours. They found that the participants with severe hepatic impairment had higher and longer "naloxone" levels detected compared with the healthy participants; however, the inactive metabolite, "naloxone 3-β-Dglucuronide" levels were similar between the two groups. They concluded that sublingual buprenorphine/naloxone combined product should be avoided for those who have severe hepatic impairment [4]. This study also suggested that naloxone is metabolized in the liver and may provide clinical effectiveness only for those who have hepatic impairment. The clinical effects of sublingual naloxone on healthy patients remain controversial.

Strickland and Burson reviewed the charts of 561 patients, 11.1% of whom were on buprenorphine/naloxone combination products while the others received mono products. The authors reported that urine "naloxone" was detected in the majority of samples; 97.8% from the 63 patients who were on the dual medication had >1 ng/ mL naloxone, and 92.7% of them had 30 ng/mL of naloxone. The authors argued that sublingual naloxone may be absorbed and thus cause unpleasant adverse effects [13].

By contrast, the pharmacological effects of sublingual naloxone have a 10-times lower binding affinity to μ opioid receptors, compared to buprenorphine, namely, rapid opioid receptor dissociation (approximately 6.5 minutes); short half-life of naloxone (60–90 minutes compared to 24–60 hours of buprenorphine); low bioavailability (estimated 3% sublingually); and first-pass bioavailablility, led to the postulation of insignificant clinical effects in sublingual naloxone. After the Food and Drug Administration (FDA) approved buprenorphine/naloxone combination medication in 2002 [24], this combined medication became the standard of care, especially after the Substance Abuse and Mental Health Services Administration (SAMHSA) warned about the misuse potentials of monotherapy [25]. However, the controversy of combined naloxone/buprenorphine versus monotherapy of buprenorphine has yet to be resolved, and further research and discussion on this topic await.

#### **4.2 Adulteration**

This study found that the amount of the film that was used to adulterated urine specimen did affect the concentration of "naloxone" detected in the urine. Submerging a small portion of the film for a short period of time (1 mm\*3 sec) in this study resulted in an average of 492 ng/mL of "naloxone" levels in the urine samples among the 12 participants. By contrast, the urine samples with full film dipped into the aliquot for 3 seconds (Full\*3 sec) yielded an average of 765.83 ng/mL of "naloxone". These numbers are very similar with those found in the study done by Warrington, et al. on the "naloxone" levels in suspected adulterated urine. They retrospectively reviewed "naloxone" levels of 1223 urine samples from two practice sites and reported that the average "naloxone" level was "633.65ng/mL (range 1-12,161 ng/mL) with 54% of samples <300 ng/mL and 8.0% having >2000ng/ mL. One of the sites had increased evidence of urine adulteration and 9.3% of the samples from this site contained > 2000 ng/ml of "naloxone" with an average of 686.8 ng/mL. The other site had no report of urine adulteration and demonstrated an average "naloxone" level of 570.9 ng/mL with 6.4% of samples containing > 2000 ng/mL. This study concluded that extremely high levels of "naloxone" can suggest urine adulteration [20]. Furo also reviewed 97 patient charts with urine drug screening results in an outpatient telemedicine OUD clinic and found that average "naloxone" level was 687.2 ng/mL that ranged from 5 ng/mL to>2000 ng/ mL with 15.30% >2000 ng/mL [26].

Heikman, et al. collected 40 urine samples from 32 patients and found much lower average of "naloxone" levels in their study. In their study design, the first group (Group 0: pre-treatment) received parental buprenorphine before buprenorphine/ naloxone treatment; the second group (Group 1: stable patients) consisted of stable patients who were on prescribed sublingual buprenorphine/naloxone treatment without any illicit substances in their urine; and the third group (Group 2: unstable patients) had prescribed sublingual buprenorphine/naloxone with unexpected urine test results. The urine samples were collected about 24 hours after the last buprenorphine/naloxone medication dispensation. The study found that the median naloxone level in the stable phase was 60 μg/L (=ng/mL, henceforth ng/mL), ranged from 5 ng/ mL to 200 ng/mL while that in the unstable phase was 70 ng/mL, ranged from 70 ng/ mL to 1700 ng/mL. They concluded that high "naloxone" level can indicate noncompliance of buprenorphine/naloxone treatment [15].

The average "naloxone" levels in the study by Heikman, et al., [15] was much lower compared with those in the studies mentioned above. This may be because *Detecting Naloxone in Adulterated Urine Samples: Can Naloxone Be Detected When… DOI: http://dx.doi.org/10.5772/intechopen.109412*

naloxone has a short half-life of 60–90 minutes [22] and because their urine collection was done approximately 24 hours after the last dose of buprenorphine/naloxone medication. The average "naloxone" levels of this current study (e.g. 492 ng/mL of 1 mm\*3 sec specimen group and 765.83 ng/mL of full\*3 sec group) of the adulterated urine samples from those who were not on buprenorphine/naloxone were similar to those of these previous studies (e.g. 687.2 ng/mL in Furo [26] and 570.9 ng/mL in Warrington, et al. [20]) with the unadulterated urine samples from those were on buprenorphine/naloxone. This similarity should be explored further in relation to the implication of pharmacokinetics and pharmacodynamics of naloxone in the system.

#### **4.3 Clinical applications**

The results of this study can be used to help clinicians interpret urine toxicology test results more accurately. In this section, seven simulated cases based on previously encountered results are discussed to present how to apply the findings of this study to the daily practice of OUD treatment. The cases and their associated laboratory values as well as the buprenorphine prescription dosage are summarized in **Table 4**.

#### *4.3.1 Case 1*

[Bup 278 ng/mL, Norbup 635 ng/mL, Bup/Norbup 0.44, Nal 687 ng/mL, Cre 133.9 mg/dL, Bup/Nal 16 mg/4 mg per day, appropriate case].

This is a typical pattern of urine toxicology results. If patients are taking "buprenorphine" daily, "norbuprenorphine" is usually higher than "buprenorphine", [16] and creatinine is within normal range (20-400 mg/dL) (The ARUP laboratory criteria). Therefore, this is an appropriate urine toxicology case for those who are compliant with buprenorphine/naloxone treatment.

#### *4.3.2 Case 2*

[Bup >2000 ng/mL, Norbup 17 ng/mL, Bup/Norbup 117.65, Nal >2000 ng/mL, Cre 97.2 mg/dL, Bup/Nal 16 mg/4 mg per day, inappropriate case].

*Bup = Buprenorphine, Norbup = Norbuprenorphine, Nal = Naloxone, Cre = Creatinine. The units are listed in the top column. The level > 2000 ng/mL was considered 2000 ng/mL for the calculations.*

#### **Table 4.**

*7 simulated cases in clinical practice and their associated laboratory values.*

This is a typical pattern of urine adulteration of having dipped buprenorphine/ naloxone film directly into the urine sample. The ratio between buprenorphine/norbuprenorphine is >50 [17]. The very high naloxone level (>2000 ng/mL) confirms this suspicion of adulteration, consistent with the results of this study.

#### *4.3.3 Case 3*

[Bup >2000 ng/mL, Norbup >2000 ng/mL, Bup/Norbup 1.0, Nal >2000 ng/mL, Cre 306.7 mg, Bup/Nal 16 mg/4 mg per day, appropriate case].

This case has a high level of naloxone >2000 ng/mL, so there is suspicion of urine adulteration; however, this is an example, in which a high naloxone level does not mean urine adulteration. As Furo's study found that 15% of urine samples had "naloxone" levels >2000 ng/mL [26], a high level of naloxone can also be due to other reasons. This case illustrates that we can use a high "naloxone" level to confirm urine adulteration only if the buprenorphine/naloxone ratio is >50:1; "naloxone" level itself cannot be the main determining factor of urine adulteration. In other words, the judgment of urine adulteration should be based on high buprenorphine/norbuprenorphine ratio. Therefore, this is an appropriate case of buprenorphine/naloxone treatment. One might wonder why is this patient's "naloxone" level so high? The answer is that this patient might be dehydrated at the time of this urine collection, indicated by the high creatinine level, so the buprenorphine, norbuprenorphine, naloxone and creatinine are all consequently very high. If this patient were well hydrated, the results should have been similar to Case 1 with a much lower creatinine level. Thus, this example should be appropriate for the buprenorphine/norbuprenorphine treatment.

#### *4.3.4 Case 4*

[Bup >2000 ng/mL, Norbup 10 ng/mL, Bup/Norbup 200, Nal <2 ng/mL, Cre 82.6 mg/dL, Bup 16 mg per day, inappropriate case].

This case is an adulteration case in which the patient is prescribed buprenorphine only medication. This patient has not taken this medication for a while, indicated by the low norbuprenorphine level. This case has a high ratio of buprenorphine/norbuprenorphine, but naloxone is undetectable, which means that prior to the urine collection, buprenorphine medication has been crushed into powder and dissolved into the sample. As a result, the ratio between buprenorphine/norbuprenorphine is high (>50), but there is undetectable naloxone level (<2 ng/mL). Undetectable naloxone level should be always suspected with buprenorphine monotherapy.

#### *4.3.5 Case 5*

[Bup >2000 ng/mL, Norbup 17 ng/mL, Bup/Norbup 117.65, Nal 5 ng/mL, Cre 179.2 mg/dL, Bup/Nal 16 mg/4 mg per day, inappropriate case].

This is another case of urine adulteration as indicated with a high buprenorphine/ norbuprenorphine ratio (>50:1). However, "naloxone" is detected at a very small amount. Because of the high buprenorphine/norbuprenorphine ratio, we expect a high level of "naloxone" if buprenorphine/naloxone was dipped in this urine sample. Otherwise, we expect undetectable level of "naloxone" if buprenorphine only medication was dissolved into the urine sample. The small amount of "naloxone's being detected means that this patient probably has taken buprenorphine/naloxone at least 24 hours before this urine collection [15], and thus there was a small amount of

#### *Detecting Naloxone in Adulterated Urine Samples: Can Naloxone Be Detected When… DOI: http://dx.doi.org/10.5772/intechopen.109412*

"naloxone" residue detected. Compared with buprenorphine, the naloxone's half-life is much shorter, and thus, a low level of naloxone can be detected while relatively higher level of buprenorphine and norbuprenorphine still remained in the system after an intermittent use of buprenorphine/naloxone. In addition, this patient tampered the urine sample with buprenorphine only medication, which is indicated by the high buprenorphine/norbuprenorphine ratio. If buprenorphine/naloxone combined medication was dipped into this urine sample, the naloxone level would have been much higher as indicated by the results of this study, unless the patient has some issues of naloxone metabolism such as the enzyme to metabolize naloxone is inhibited by certain medication(s) or genetically. This patient is prescribed with buprenorphine/naloxone combined medication, so it is uncertain as to why this patient added additional buprenorphine to the urine.

#### *4.3.6 Case 6*

[Bup >2000 ng/mL, Norbup 2000 ng/mL, Bup/Norbup 1.0, Nal 2000 ng/mL, Cre 82.5 mg/dL, Bup/Nal 16 mg/4 mg per day, appropriate case].

This case has high "buprenorphine", "norbuprenorphine" and "naloxone" levels, so we can speculate dehydration; however, "creatinine" level is not as high as Case 3, and therefore, we can rule out dehydration. The ratio between buprenorphine to norbuprenorphine is <50:1, so it is unlikely that this sample is adulterated. This might be a case with high metabolism patient, which causes high levels of all components. This is rare but can happen. Thus, this is another example of a high naloxone level, but it does not mean urine adulteration.

#### *4.3.7 Case 7*

[Bup 286 ng/mL, Norbup 569 ng/mL, Bup/Norbup o.5, Nal 71 ng/mL, Cre 67.5 mg/ dL, Bup 16 mg per day due to naloxone allergies, inappropriate case].

This patient has an appropriate "buprenorphine" to "norbuprenorphine" ratio (<50:1) with low level of "naloxone"; however, this result is not appropriate because this patient was on buprenorphine monotherapy due to naloxone allergies. The detected "naloxone" suggests that she has been taking buprenorphine/naloxone despite her being prescribed buprenorphine monotherapy. Buprenorphine only product has a higher street value than buprenorphine/norbuprenorphine combined medication by approximately 20% [27]. Therefore, some patients might trade their buprenorphine with buprenorphine/naloxone combination medication for the marginal profit.

In summary, as this study found, a high concentration of "naloxone" can confirm suspected urine adulteration if buprenorphine/norbuprenorphine ratio is >50:1. However, a high level of "naloxone" alone does not necessarily involve urine adulteration, especially without a high ratio of buprenorphine/norbuprenorphine. The patient might have dehydrated at the time of urine collection, or the patient might be a fast metabolizer of buprenorphine/naloxone. Therefore, we should monitor creatinine level because it can indicate the hydration status of the patient [28], as dehydration can cause high levels of "naloxone" in addition to high "buprenorphine" and "norbuprenorphine" levels. Furthermore, a patient with high metabolism can cause high levels of "buprenorphine", "norbuprenorphine" and "naloxone" without a corresponding high "creatinine" level. Finally, if "naloxone" is observed in urine sample, we can suspect that the patient is taking or had taken buprenorphine/naloxone

combined medication, while if no naloxone is identified, the patient is on buprenorphine monotherapy.

#### **4.4 Clinical implications**

The results of this study have implications on clinical practice in the care of OUD patients. With the increased use of unobserved urine toxicology collection in practice [29], the appropriate interpretation of urine drug tests remains a challenging but vital component of comprehensive patient care. Results from this study may suggest that the "naloxone" detected in adulterated urine samples may be dissolved "naloxone" instead of metabolized naloxone, or a fraction of naloxone at least. There are also healthcare policy implications with the controversy of mono-product formulation use in the United States as a harm reduction approach in the treatment of OUD [9]. Buprenorphine mono-product is used widely in other areas of the world [30] and has been suggested as a medication treatment option for patients struggling with adverse effects, thought to be potentially from naloxone absorption from sublingual buprenorphine/naloxone combined medication [9]. With increasing research findings that raise the concern of using "naloxone" levels in urine as an indicator of absorption of naloxone and potentially the cause of patient-reported adverse effects, these findings reinforce the recommendation for clinicians to also consider possible urine adulteration, resulting in elevated "naloxone" levels.

A high level of "naloxone" itself should trigger further assessment of the patient buprenorphine/naloxone regimen; however, by itself there is insufficient evidence to guide care. This information should be synthesized with other available urine toxicology screen parameters (buprenorphine, norbuprenorphine, creatinine and buprenorphine/norbuprenorphine ratio) to better inform the clinical picture. Moreover, the continuation of buprenorphine as a medication for OUD yields more benefits than risks in the public health approach of addressing opioid overdose mortality. Urine toxicology is only one piece of information to be used in a clinical evaluation. The overall goal of improvement of multiple biopsychosocial domains and patient-centered outcomes remains the driving force in clinical decision-making.

Finally, the results of this study might support the stipulation that sublingual naloxone can be minimally absorbed and metabolized in the system and thus exerts insignificant effects clinically when taken sublingually, which might consequently contribute to the controversy on buprenorphine/naloxone combined product versus buprenorphine monotherapy in the buprenorphine induction process [31, 32]. The results of this study would give us an insight on these controversial issues.

#### **4.5 Limitations**

The limitations of this study include the small sample size and reliance on subjects' report of substance and medication use. Findings from this study may be used to apply for funding to support a larger sample size study and additional substance testing of all samples. While the potential effects of unreported substance use are unknown, the overall trend in this study's results is unlikely to be impacted. An additional limitation is that this study evaluated the addition of varying buprenorphine/ naloxone levels via film into water and urine samples as a proxy for adulteration. The actual adulteration techniques used by individuals may vary widely. A clinical trial evaluating "naloxone" levels in adulterated and non-adulterated urine samples of

*Detecting Naloxone in Adulterated Urine Samples: Can Naloxone Be Detected When… DOI: http://dx.doi.org/10.5772/intechopen.109412*

patients prescribed buprenorphine/naloxone would be difficult in nature. To address the range in adulteration techniques, we used multiple categories of surface areas, dipping duration, temperatures, and concentrations of both urine and water samples to assimilate a variety of methods and observe the resulting "naloxone" levels. Finally, we also acknowledge that some clinicians use urine toxicology that do not report "naloxone" levels in certain clinic practices, and therefore these findings may not be clinically useful to all providers.

#### **5. Conclusions**

The urine "naloxone" level by dissolving buprenorphine/naloxone film is very sensitive to the area and the time that the film come into contact with the urine samples. Attempted adulteration of the urine sample is likely yield supratherapeutic levels of "naloxone". At this time, there is no consensus as to what level to set the "naloxone" concentration as a parameter to determine the legitimacy of patient urine samples except some research reports. While "naloxone" level is a simple component to test for in resource-challenged practices, other metabolites such as "buprenorphine" and its metabolite levels should be examined to guide clinical decisions. In summary, the results of this study have provided a further insight into interpreting urine drug screening test results for OUD patients with buprenorphine treatment. Strict monitoring of urine toxicology is by no means a punitive process but to improve the outcome of OUD treatment. Future study can focus on differentiating naloxone molecules that were dissolved "naloxone" versus those that were renally excreted, which can enhance our understanding on the pharmacokinetics and pharmacodynamics of naloxone.

#### **Acknowledgements**

We would like to express our sincere and deep appreciation for the editors and reviewers who provided us with valuable feedback. We would also thank Editage for editing the final version of this manuscript.

#### **Authors' contributions**

H.F. carried out the research experiment and wrote the first draft of the paper excerpt discussion and conclusion sections. T.H. wrote the discussion and conclusion sections and completed the manuscript with support with S.A. who edited the draft form of this manuscript. Y.Z. completed the manuscript by editing the final version.

#### **Funding**

Not applicable.

#### **Competing interests**

There is no conflict of interests among the authors.

### **Consent for publication**

All authors agree with publishing this manuscript.

#### **Note**

Correspondence concerning this article should be addressed to Hiroko Furo (furo@uthscsa.edu), Department of Psychiatry and Behavioral Sciences, the University of Texas Health at San Antonio, San Antonio, TX, USA.

### **Ethics approval and consent to participate**

The Institutional Review Board (IRB) application to the University of Texas Health at San Antonio was approved (IRB Protocol ID: 20220593HU), and the written consents were obtained by all participants.

### **Availability of data and materials**

The datasets produced for the data analysis for this study are not publicly available due to the confidentiality of participants but are available in a de-identified form from the corresponding author on request.

### **Abbreviations**

*Detecting Naloxone in Adulterated Urine Samples: Can Naloxone Be Detected When… DOI: http://dx.doi.org/10.5772/intechopen.109412*

### **Author details**

Hiroko Furo1,2,3,4\*, Tony Lin4 , Yi Yuan Zhou2 and Sarah Abdelsayed4

1 Department of Psychiatry and Behavioral Sciences, The University of Texas Health at San Antonio, San Antonio, TX, USA

2 Department of Pathology, The University of Texas Health at San Antonio, San Antonio, TX, USA

3 Department of Biomedical Informatics, State University of New York (SUNY) at Buffalo, Buffalo, NY, USA

4 Department of Family Medicine, State University of New York (SUNY) at Buffalo, Buffalo, NY, USA

\*Address all correspondence to<EMAIL_ADDRESS>
© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **References**

[1] "Naloxone". Drugbank Online. 11/28/22. https://go.drugbank.com/ drugs/DB01183

[2] Koyyalagunta D. Opioid analgesics. In: Pain Management. Netherlands: Elsevier; 2007. pp. 939-964

[3] Jordan MR, Morrisonponce D. Naloxone. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022. Available from: https://www.ncbi.nlm.nih.gov/books/ NBK441910/ . [Accessed: Jul 11, 2022]

[4] Nasser AF, Heidbreder C, Liu Y, et al. Pharmacokinetics of sublingual buprenorphine and naloxone in subjects with mild to severe hepatic impairment (child-pugh classes A, B, and C), in hepatitis C virus-seropositive subjects, and in healthy volunteers. Clinical Pharmacokinetics. 2015;**54**:837-849. DOI: 10.1007/s40262-015-0238-6

[5] Coe MA, Lofwall MR, Walsh SL. Buprenorphine pharmacology review: Update on transmucosal and longacting formulations. Journal of Addiction Medicine. 2019;**13**(2):93-103. DOI: 10.1097/ADM.0000000000000457

[6] Available from: https:// www.fda.gov/media/100429/ download#:~:text=Naloxone%20 is%20absorbed%20not%20only,is%20 within%201%2D2%20minutes

[7] Preston KL, Bigelow GE, Liebson IA. Effects of sublingually given naloxone in opioid-dependent human volunteers. Drug and Alcohol Dependence. 1990;*25*(1):27-34. DOI: 10.1016/0376-8716(90)90136-3

[8] NIDA. Naloxone DrugFacts. National Institute on Drug Abuse website.

2022 Available from: https://nida.nih. gov/publications/drugfacts/naloxone [Accessed: November 26, 2022]

[9] Blazes CK, Morrow JD. Reconsidering the usefulness of adding naloxone to buprenorphine. Frontiers in Psychiatry. 2020;**11**:549272. DOI: 10.3389/ fpsyt.2020.549272

[10] Mendelson J, Jones RT, Welm S, et al. Buprenorphine and naloxone combinations: the effects of three dose ratios in morphine-stabilized, opiate-dependent volunteers. Psychopharmacology. 1999;**141**(1):37-46. DOI: 10.1007/s002130050804

[11] Tzatzarakis MN, Vakonaki E, Kovatsi L, et al. Determination of buprenorphine, norbuprenorphine and naloxone in fingernail clippings and urine of patients under opioid substitution therapy. Journal of Analytical Toxicology. 2015;**39**(4):313-320

[12] Stone, JA Pesce AJ, Fitzgerald RL. 2017 Fake news, alternative facts or just normal pharmacokinetics? High urine naloxone concentrations in patients prescribed sublingual buprenorphine– naloxone (BNX). MSACL EU Abstract

[13] Strickland DM, Burson JK. Sublingual absorption of naloxone in a large clinical population. Journal of Drug Metabolic Toxicology. 2018;**09**(02):1-4

[14] Rosado J, Walsh SL, Bigelow GE, Strain EC. Sublingual buprenorphine/ naloxone precipitated withdrawal in subjects maintained on 100mg of daily methadone. Drug and Alcohol Dependence. 2007;**90**(2-3):261-269. DOI: 10.1016/j.drugalcdep.2007.04.006

[15] Heikman P, Häkkinen M, Gergov M, Ojanperä I. Urine naloxone concentration *Detecting Naloxone in Adulterated Urine Samples: Can Naloxone Be Detected When… DOI: http://dx.doi.org/10.5772/intechopen.109412*

at different phases of buprenorphine maintenance treatment: Urine naloxone concentration at buprenorphine maintenance treatment. Drug Test Analysis. 2014;**6**(3):220-225

[16] Furo H, Schwartz DG, Sullivan RW, Elkin PL. Buprenorphine dosage and urine quantitative buprenorphine, norbuprenorphine, and creatinine levels in an office-based opioid treatment program. Substance Abuse. 2021;**15**:1-9<PHONE_NUMBER>1061749. DOI: 10.1177/11782218211061749

[17] Accurso AJ, Lee JD, McNeely J. High prevalence of urine tampering in an office-based opioid treatment practice detected by evaluating the norbuprenorphine to buprenorphine ratio. Journal of Substance Abuse Treatment. 2017;**83**:62-67. DOI: 10.1016/j. jsat.2017.10.002

[18] Donroe JH, Holt SR, O'Connor PG, Sukumar N, Tetrault JM. Interpreting quantitative urine buprenorphine and norbuprenorphine levels in officebased clinical practice. Drug and Alcohol Dependence. 2017;**180**:46-51. DOI: 10.1016/j.drugalcdep.2017.07.040

[19] Suzuki J, Zinser J, Issa M, Rodriguez C. Quantitative testing of buprenorphine and norbuprenorphine to identify urine sample spiking during office-based opioid treatment. Substance Abuse. 2017;**38**(4):504-507. DOI: 10.1080/08897077.2017.1356796

[20] Warrington JS, Booth K, Warrington GS, et al. Use of urinary naloxone levels in a single provider practice: a case study. Addiction Science & Clinical Practice. 2020;**15**:3. DOI: 10.1186/s13722-020-0178-9

[21] Burns MM, Law TC, Rifai N, Shannon MW. Naloxone produces a positive urine opiate screen. Pediatric Research. 1999;**45**(7):80-80

[22] Clarke SFJ, Dargan PI, Jones AL. Naloxone in opioid poisoning: Walking the tightrope. Emergency Medicine Journal. 2005;**22**:612-616

[23] Available from: https://www.ibm. com/spss

[24] "Buprenorphine". Drug enforcement administration—diversion control division: Drug and chemical evaluation section. 11/28/22. Available from: https://www.deadiversion.usdoj.gov/ drug\_chem\_info/buprenorphine.pdf

[25] Walsh L. Buprenorphine. Available from: https://www.samhsa.gov/ medication-assisted-treatment/ treatment/buprenorphine,

[26] "Interpretation of urine drug test results of buprenorphine, norbuprenorphine, naloxone, creatinine levels in buprenorphine treatment program. Work-in-Progress. Furo H.

[27] Hswen Y, Zhang A, Brownstein JS. Leveraging black-market street buprenorphine pricing to increase capacity to treat opioid addiction, 2010-2018. Preventive Medicine. 2020;**137**:106105. DOI: 10.1016/j. ypmed.2020.106105

[28] Weigand TJ, editor. Use and interpretation of buprenorphine metabolite profiles during maintenance treatment. In: Poster Presented at: 47th American Society of Addiction Medicine (ASAM) Annual Conference, April 14-17. MD: Baltimore; 2016

[29] Rao PN, Jotwani R, Joshi J, Gulati A, Mehta N. Reevaluating chronic opioid monitoring during and after the COVID-19 pandemic. Pain Management. 2020;**10**(6):353-358. DOI: 10.2217/ pmt-2020-0063

[30] Yokell MA, Zaller ND, Green TC, Rich JD. Buprenorphine and

buprenorphine/naloxone diversion, misuse, and illicit use: an international review. Current Drug Abuse Reviews. 2011;**4**(1):28-41. DOI: 10.2174/1874473711104010028

[31] Rzasa Lynn R, Galinkin JL. Naloxone dosage for opioid reversal: current evidence and clinical implications. Therory of Advanced Drug Safety. 2018;**9**(1):63-88. DOI: 10.1177/2042098617744161

[32] Dooley J, Gerber-Finn L, Antone I, Guilfoyle J, Blakelock B, Balfour-Boehm J, et al. Buprenorphinenaloxone use in pregnancy for treatment of opioid dependence: Retrospective cohort study of 30 patients. Canadian Family Physician. 2016;**62**(4):e194-e200

### **Chapter 7**

## Usefulness of Urine Tests in the Prevention, Diagnosis, Treatment and Prognosis of Pathologies Present during Pregnancy

*Noren Villalobos*

#### **Abstract**

Pregnancy produces physiological changes in the woman necessary to be able to bring it to a happy term. However, they can favor the development of pathologies in various organs and systems, ranging from urinary infections, diabetes mellitus or gestational to hypertensive disorders of pregnancy. Which produce substances that are excreted through the urine. There is also excretion of metabolites which can be evaluated for the diagnosis and prognosis of certain chromosomopathies. These substances, when measured or quantified, provide bases for diagnosis, prevention, and allow decisions to be made regarding timely treatment in many of them.

**Keywords:** urinalysis, pregnancy, pathologies of pregnancy, diagnosis, urinary tract infections

#### **1. Introduction**

Pregnancy (EMB) is considered a physiological state where the maternal organism must adapt to the allograft it carries in its body [1]. To do this, it undergoes a series of modifications or physiological changes that allow it to adapt to the EMB in a continuous and dynamic way, which occur at the level of all organs and systems, and in turn are influenced by multiple factors that include the age of the woman, previous pregnancies, physical and nutritional status, presence of previous diseases or pathologies, among others [2]. These changes regress after the birth of the fetus in a period of approximately 40 days or until the moment the menstrual cycle resumes, returning the mother to the state prior to pregnancy and preparing her body for a new pregnancy [1, 2].

These changes known as gravid or physiological modifications of pregnancy (MFE) can be monitored through laboratory tests and diagnostic aid images (such as ultrasound) which can be routinely performed quarterly in normal EMB or vary their frequency in those cases in which complications or pathologies associated with it appear, which are capable of modifying its course or aggravating or unmasking a pre-existing problem [3].

#### **1.1 MFEs comprise**

The kidney is one of the organs that undergo important changes with the EMB which begin from the 6th week beginning with anatomical changes that include dilation of the pelvis and renal calyces and ureters, all this under the action of pregnancy hormones. Progesterone and estrogens [1, 2]. This causes an increase in urinary dead space, at the same time that renal vascularization increases with an increase in interstitial volume, which in turn causes an increase in kidney length of approximately 1 to 1.5 cm. compared to a normal adult (4.5). The kidney recovers its normal size approximately 6 months postpartum, even when the puerperium has already ended.

All of this leads to changes in renal physiology from the hemodynamic point of view, glomerular filtration, water and electrolyte management, and changes in the renin-angiotensin-aldosterone system [4].

A predisposition to the appearance of urinary tract infections (UI) occurs due to compression of the right ureter by dextrorotation of the uterus, to which the sigmoid colon contributes, which compresses the right ureter, and to the decrease in its peristalsis due to the action of progesterone, which favors the appearance of hydronephrosis. in the right kidney, slowing of urine transit through the ureter causing retrograde stasis. Contributing to this is the fact of the residual presence of urine in the urinary bladder, with a decrease in its tone, and a relative increase in its capacity as the EMB progresses due to uterine compression, which even produces reflux into the ureter, and may be up to be for 24 hours or more without being eliminated properly. Its mucosa becomes hyperemic and edematous, making it susceptible to infections and trauma [4].

Renal blood flow increases between 35 and 60%, therefore glomerular filtration increases between 50 and 60% together with the reabsorption of water and electrolytes to maintain the hydroelectrolytic balance [4–6].

During EMB, amino acids and water-soluble vitamins are lost in greater amounts than in non-EMB. Creatinine and uric acid decrease so that normal values for pregnant women are considered normal at 0.8 mgrs.%, and a greater increase is considered suspicious of kidney disease. Creatinine clearance increases by 30%. therefore, values less than 1 37 ml must be evaluated. Glycosuria is not necessarily abnormal and there may be non-significant proteinuria of 115 to 260 mg/day [1].

#### **2. Utilization of urinalysis during pregnancy**

#### **2.1 Urinary tract infections**

The appearance of urinary tract infections (UTI) is possibly the most frequent pathology during EMB, with a prevalence ranging between 14 and 48% [7], favored by the MFE that occur in the urinary tract and the alkalinization of the urinary tract. Urine [8, 9]. It is associated with other complications of EMB including pyelonephritis, preterm delivery, low birth weight newborns, and increased perinatal mortality [10, 11].

Preterm delivery (PP) is the main complication associated with UTIs, since bacterial infection in maternal and fetal tissues causes the release of endotoxins and exotoxins, cytokines, tumor necrosis factor, interleukin-1 beta, interleukins 6 and 8, granulocyte colony-stimulating factor and other factors, which stimulate the production and release of prostaglandins, leading to uterine contractions and neutrophil activity, which in turn stimulate the synthesis and production of metalloproteinases, causing membrane rupture and collagen remodeling of the cervix [12].

UTI is defined as the presence of 100,000 germs per cubic centimeter (cc) of urine in asymptomatic patients, or greater than 100,000 germs per cc of urine and leukocytes greater than 7 leukocytes per cc of urine in a symptomatic patient [10]. In most cases, it begins in the urinary bladder, favored by MGE, which in turn will allow it to ascend to the kidney [7].

#### *2.1.1 Types of urinary tract infection*

Asymptomatic bacteriuria: It is the presence of 100,000 organisms per milliliter (ml) in 2 consecutive cultures with the absence of symptoms, constituting a 40% risk factor for acute cystitis and 25 to 30% for pyelonephritis in pregnancy [9].

UTI: Presence of 100,000 organisms per ml of urine in asymptomatic patients or more than 100,000 accompanied by more than 7 cells in a symptomatic patient [9].

Cystitis: It constitutes the lower UTI characterized by inflammation of the urinary bladder due to bacterial causes or not (radiation) or viral. It occurs in 1 to 2% of pregnant women, being negative in 60% in the first screenings. It is complicated between 15 to 50% with pyelonephritis [9].

Pyelonephritis: upper UTI occurs in approximately 0.5 to 2% of all pregnancies [7, 9].

Now, what should we study in the urine test to help us diagnose UTIs or other pathologies.

#### **2.2 Urinary sediment**

The urinary sediment is obtained from a urine sample centrifuged at 2000 revolutions per minute, from which different types of cells originating from the urinary tract epithelium, or other cells such as leukocytes, red blood cells, platelets, renal cells, hyaline casts, are obtained. Leukocyte casts, amorphous phosphates, calcium crystals, uric acid, urates, lipid droplets, cholesterol crystals, proteins [13].

The presence of organisms such as bacteria, which can be typical of the urinary tract or contamination of the vagina, is frequent, as well as protozoa (vaginal trichomonas) and fungi such as candida vaginalis, as well as menstrual products and even

spermatozoa [13]. Always contamination vaginal is accompanied by leukocytes and vaginal epithelial cells, so it is necessary to examine the patient's vagina with a speculum when we have these results. Gardnerella vaginalis is another germ that causes infections and vaginal discharges that easily contaminate the urine test.

In the urine analysis, the presence of leucocyte esterase can be evaluated, which is an enzyme secreted by neutrophils, constituting a marker of infection [14, 15]. It has a sensitivity of 83% and a specificity of 78% [16].

Another test used is the nitrite test. It is based on the reduction of nitrates to nitrites carried out by enterobacteria by action of the enzyme nitrite reductase, for which it is necessary that the urine be found without mobilizing for 4 hours, its specificity being that it does not react with other substances [17]. Its sensitivity is 53% and a specificity of 78% [16, 18].

When both studies are combined, they reach a sensitivity of 98% and a specificity of 95%, which makes them very useful in the diagnosis of urinary tract infections [17].

#### **2.3 Ph in urine**

The pH of the urine covers the limits of acidity and alkalinity from 5.0 to 8.8. Ph greater than or equal to 6.0 is considered altered [17]. Its determination is a reflection of the buffered ion concentration and not a net measure of acids [18].

Acidic urine, with a pH less than 4.5, may be a reflection of metabolic acidosis, such as diabetic ketoacidosis, which can affect a patient with poorly controlled gestational diabetes or type I or II diabetes during pregnancy. Cases of patients with chronic diarrhea, a diet rich in meat, or in cases of chronic respiratory failure [18].

In contrast, alkaline urine presents with a pH greater than 8.0 and may be due to renal tubular acidosis, metabolic alkalosis which may be caused by pregnancy vomiting in the first trimester or in the case of hyperemesis gravidarum, or in the case administration of diuretics, in respiratory alkalosis or in cases of urinary infections by urease-producing germs such as Proteus miriabilis or in cases of a vegetarian diet [18].

In patients with alkanuria an alkaline pH is reported, which occurs in the presence of bacteria, urinary infection or diets rich in citrus or vegetables or the presence of certain drugs. It is also the product of the presence of lithiasis due to calcium carbonate, calcium phosphate and magnesium phosphate. However, the presence of acid urine is identified with aciduria, the product of respiratory or metabolic acidosis. When there is tubular acidosis, the urine is alkaline and the blood pH shows acidity [19].

During the pregnancy motivated by the MFE, changes in the breathing of the pregnant woman begin to appear from the eighth week, they begin with hyperventilation and a slight dyspnea which increases gradually throughout the pregnancy due to anatomical modifications by increasing the internal vertical diameters. and circumference of the ribcage when the uterus increases in size and volume, which in turn compresses the abdominal viscera against the diaphragm, thereby limiting its mobility, thereby increasing intra-abdominal pressure, which has its impact at the of lung volumes. This in turn causes the reduction of PCO2 to 30 mmHg by the action of progesterone, while increasing PO2 to 107 mmHg. Serum bicarbonate decreases to 20 mEq/L. By increasing renal excretion, it modifies the pH from 0.02 to 0.06 as a metabolic compensation for respiratory alkalosis (4.5).

*Usefulness of Urine Tests in the Prevention, Diagnosis, Treatment and Prognosis of Pathologies… DOI: http://dx.doi.org/10.5772/intechopen.109540*

All of this has as a consequence that the urine tends to become alkaline with a Ph of 6.0 or more, which, together with the gravid changes that affect the urinary system, will favor the appearance of UTI.

#### **2.4 Hormonal study in a urine sample**

Human chorionic gonatropin (HCG) is a protein synthesized by embryonic tissues, made up of 2 amino acid chains called alpha and beta. Its secretion is related to the growth of trophoblastic tissue during pregnancy, reaching its maximum levels between weeks 3 and 9 of the same [20].

Its concentration varies substantially in serum and urine [20]. For this reason, excretion in urine has allowed the development of pregnancy tests due to their levels in urine to make a diagnosis of it in a simple way, which can be carried out by patients without the need to go to a laboratory, but without specifying the conditions. Weeks of gestation, which is done by evaluating the plasmatic levels of its beta fraction.

It is considered responsible for the nausea and vomiting of pregnancy. Its presence, in addition to allowing the diagnosis of normal pregnancy, allows the diagnosis of ectopic pregnancy or gestational trophoblastic disease in any of its forms, which in most cases can occur with hypertensive disorders of pregnancy when its levels quadruple the values of the normal pregnancies. However, it can give false negatives when performed between weeks 41 and 109 of pregnancy, due to the decrease in trophoblastic tissue that produces it [20].

#### **2.5 Presence of metabolites in urine**

#### *2.5.1 Ketone bodies*

The presence of ketone bodies in urine during EMB may be related to the presence of diabetes mellitus. It must be known if this diabetes was type I or II and was present before it or if it is gestational diabetes that develops during it from the 24th week of pregnancy and which can disappear after it or the patient remains diabetic. Type II [21].

The MFE that leads to changes in energy distribution during pregnancy must be taken into account [21]. At the beginning of EMB, there is an increase in insulin sensitivity with a decrease in fasting plasma glucose levels and a slight decrease in hepatic glucose production. At the end of the first trimester and during the second trimester of gestation, insulin sensitivity decreases, finding its highest level in the third trimester, with a 30% increase in hepatic glucose secretion and a 40–50% decrease in glucose mediated by insulin, leading to decreased insulin sensitivity with a predisposition to accelerated fasting ketosis and increased fasting maternal glycemia and fatty acids [21].

Gestational diabetes is a common disorder that can affect pregnancy, capable of causing maternal and fetal complications such as neural tube malformations that include anencephaly, spina bifida, renal agenesis and hypoplasia, cardiac disorders such as tetralogy of Fallot, atrioventricular septal defects., coarctation of the aorta, ventricular septal defect, and musculoskeletal diseases and injuries such as agenesis of the sacrum, cleft palate, and high risk of preeclampsia, preterm delivery, fetal malformations, and cesarean sections due to the presence of fetal macrosomia [21–23].

Diabetic ketoacidosis in gestational diabetes has an incidence of 0.3 to 5%, so it is always necessary to rule out a history of type I and II diabetes, which are more easily and severely complicated than in non-pregnant patients [24].

#### *2.5.2 Proteinuria*

A separate chapter is constituted by proteinuria in pregnancy, which is extremely important for the diagnosis, evaluation, and prognosis of hypertensive disorders of pregnancy, preeclampsia-eclampsia, and its complications. It occurs in 2 to 10% of pregnancies [25] and is responsible for 26% of maternal deaths in Latin America and 9% in Africa and Asia.

Preeclampsia affects the endothelium systemically, proving a generalized endotheliosis that reaches all organs of the economy. In the kidney, at the level of the renal glomerulus, it produces glomeruloendotheliosis, which is manifested by proteinuria and oliguria that improves after fetal extraction [25].

It is necessary and important to know the classification of hypertensive disorders of pregnancy:

It is necessary to consider the presence of renal disease prior to pregnancy, which can cause proteinuria, for which it is necessary that it be present before the 20th week of gestation [27]. Its appearance after week 20 may constitute one of the first signs of the appearance of hypertensive disorders of pregnancy: preeclampsia [26].

For the diagnosis of proteinuria it is necessary to collect 24-hour urine with values equal to or greater than 300 mg/day [26].

In the presence of proteinuria, it is necessary to rule out different nephropathies ranging from chronic kidney disease in which a progression of kidney disease is considered [28], diabetes mellitus, human immunodeficiency virus (HIV) infection or autoimmune diseases such as Lupus. systemic erythematosus [29]. For this reason, any proteinuria greater than 300 mg/day needs to be evaluated and the respective differential diagnoses made, especially in the presence of autoimmune diseases.

#### *Usefulness of Urine Tests in the Prevention, Diagnosis, Treatment and Prognosis of Pathologies… DOI: http://dx.doi.org/10.5772/intechopen.109540*

Since preeclampsia is a cause of maternal morbidity and mortality in many countries [25], methods have been sought to simplify the diagnosis of proteinuria in pregnancy. One of the simplest is using Robert's reagent which produces protein precipitation forming a clear halo in a test tube which contains a urine sample. Densitometers have also been used to measure the increase in urinary density due to the increase in the proteins present in them. Its biggest disadvantage is that it can produce false positives, in which case it is necessary to resort to other tests to verify its results.

At present, test strips are used for a quick and simple diagnosis of proteinuria, easy to handle and apply both by primary health personnel in a prenatal consultation, and for use by the patient at home [30]. Although they can give results as false positives or negatives, motivated by the fact that the presence of pathologies prior to pregnancy or not must be known, it is useful in patients with blood pressures of 140/90 mmHg, for monitoring at home, which allows go to a care center if they are positive [30].

Another method that has been used to diagnose proteinuria in hypertensive disorders of pregnancy is the use of sulfosalicylic acid, looking for a fast, simple, economical and reproducible method for health personnel at any level. This chemical reagent is capable of producing protein precipitation through urine acidification. It has a sensitivity of 41.1% and a specificity of 97.7% [27].

Gestational proteinuria has been described in the absence of hypertensive disorders of pregnancy, which appears after 20 weeks of pregnancy. A careful evaluation of the same is necessary [31] motivated by the fact that previous pathologies must be ruled out, and take into account that it may be an early sign of preeclampsia [32].

Investigators have been looking for another method for the diagnosis of preeclampsia through urinalysis, which is why the presence of podocytes in urine or podocyturia has been described [33]. The podocyte is a cell that forms part of the basal epithelium of the glomerulus which is affected by renal pathologies, but it was thought that it was not altered in preeclampsia, but when the glomeruloendotheliosis of preeclampsia develops, these are affected. For this reason, the study of podocyturia as a diagnostic method for preeclampsia has been proposed. However, it is also present in cases of chronic arterial hypertension, diabetes mellitus and gestational diabetes, lupus nephritis, and chronic membranous nephropathy [30, 33]. For its study, synaptopodin is used as a marker, which is a protein that binds the actin of the podocytes with the cytoskeleton of the cells [33, 34].

#### *2.5.3 Other analyzable metabolites in urine samples*

Another method used for the diagnosis, evolution and prognosis of hypertensive disorders of pregnancy is the creatinine protein index. It is used as a simpler and faster option to perform proteinuria in 24 hours. It has a sensitivity of 90% and a specificity of 80% [35, 36].

Studies are underway to develop other methods for examining urine samples and using nuclear magnetic resonance techniques to diagnose the presence of specific metabolites or biomarkers for diagnosis of preeclampsia, gestational diabetes, preterm labor, and trisomy 21 [37].

With the appearance of the omics revolution, where through the analysis of metabolites and proteins of DNA and RNA in order to carry out diagnoses and treatments of different pathologies. These metabolomics search for low molecular weight cellular compounds such as carbohydrates, amino acids, peptides, nucleic acids, organic acids, vitamins, and lipids. They can be detected using nuclear magnetic

resonance spectrometry methods in samples of blood, urine, amniotic fluid, tissue secretions, and placental tissue. These data are evaluated through computer programs where they are analyzed, studied to give their interpretation and use these data in prevention, evolution, treatment and prognosis.

These studies can be carried out at the prenatal level, during the control itself, and they can be carried out through a urine sample [38].

Diaz et al. [39] in urine samples from the 14th week of pregnancy, searched for metabolic signatures using nuclear magnetic resonance metabolomin, which revealed specific urinary metabolic signatures for malformations of the central nervous system, trisomy 21, preterm delivery, diabetes pregnancy, intrauterine growth restriction and preeclampsia, demonstrating the value of the urinalysis profile as a complementary method of diagnosis and early prediction of various disorders that occur during pregnancy [39].

Cantowine et al. [40] found urinary concentrations of Bisphenaol A and Phosphate, a metabolite which are man-made products for industrial use in a wide variety of products ranging from the lining of canned food containers, water bottles and pipes water supply, products that are released in an innocuous way to the general population throughout the world, the general population being exposed to them.

It has been shown that BFA can affect the proliferative process of trophoblast cells through an estrogen receptor with an effect of apoptosis of trophoblast cells through tumor necrosis factors which act on the placenta and therefore on the development of preeclampsia [40].

Taking into account that preeclampsia occurs more frequently in primiparous women, the use of Fit-1 tyrosine kinase has been proposed, which constitutes a promising biomarker for preeclampsia obtained from a urine sample. It is a growth factor antagonist and vasoconstrictor and sensitizes the endothelium to respond to stress and endothelial dysfunction. The study is performed with nuclear magnetic resonance spectrophotometry. The Fit-1 measures moderate to severe placental dysfunction, knowing that the development of preeclampsia occurs due to inadequate placentation with abnormal development of placental vessels at the time of trophoblastic invasion, creating high-resistance vessels instead of low-resistance ones. Resistance that occurs in normal pregnancies. For this reason, it is capable of measuring the development of preeclampsia [41].

Other metabolites and biomarkers developed from a urine sample include increased excretion of amino acids as a result of kidney damage from preeclampsia. Choline increases in these patients while glycine decreases at the same time [42].

#### **3. Conclusions**

The physiological modifications of the pregnancy through its adaptive changes, favor the development of the pregnancy, keep the expectant mother in balance to achieve its completion with the best results. However, in turn they can contribute to the appearance of pathologies caused by the lack of adaptation or poor adaptation to it, such as hypertensive disorders of pregnancy, gestational diabetes, or UTI, among others. In the effort to prevent, diagnose, treat and have an adequate prognosis, it is sought to be able to make simple and reliable diagnoses and the evaluation of uranalysis is one of the simplest methods that we have. The sample is easy to obtain and its analysis ranges from the use of reactive tapes to the diagnosis of glycosuria, proteinuria or a UTI. Urinary sediment and Ph allow us complementary diagnoses

*Usefulness of Urine Tests in the Prevention, Diagnosis, Treatment and Prognosis of Pathologies… DOI: http://dx.doi.org/10.5772/intechopen.109540*

that make us suspect other pathologies such as pyelonephritis, gallbladder and renal lithiasis, facilitating their diagnosis. We must always clinically evaluate the patient according to the signs and symptoms they present in order to make the most assertive diagnosis possible. The presence of proteinuria should always make us suspect a hypertensive disorder of pregnancy, although its absence does not thus rule it out from the presence of renal pathologies or other systemic diseases present before pregnancy. The development of new techniques for evaluating a urine sample are the next stage in the diagnosis of pathologies through the metabolites excreted in the urine, which include the diagnosis of chromosomopathies, for which the urine test in pregnancy reaches every ever-greater importance.

#### **Conflict of interest**

"The authors declare no conflict of interest."

### **Author details**

Noren Villalobos1,2

1 High Risk Obstetric Service, Department of Obstetrics and Gynecology, University Hospital of Maracaibo, Dr. Armando Castillo Plaza Maternity, Maracaibo, Venezuela

2 Medicine School, School of Medicine, University of Zulia, Maracaibo, Venezuela

\*Address all correspondence to<EMAIL_ADDRESS>
© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **References**

[1] Tejada Pérez P, Cohen A, Font Arreaza IJ, Bermúdez C, Schuitemaker Requena JB. Modificaciones fisiológicas del embarazo e implicaciones farmacológicas: maternas, fetales y neonatales. Revista de Obstetricia y Ginecología de Venezuela. 2007;**67**(4):246-267

[2] Carrillo-Mora P, García-Franco A, Soto-Lara M, et al. Cambios fisiológicos durante el embarazo normal. Revista de la Facultad de Medicina de la UNAM. 2021;**64**(1):39-48. DOI: 10.22201/ fm.24484865e.2<IP_ADDRESS>

[3] Vinturache A, Khalil A, GLob. Maternal physiological changes in pregnancy in the continuous textbook, women's medicine series – obstetrics module. In: Khalil A, editor. Vol. 4. London: GLOWM; 2021. pp. 1-39

[4] Vinturache A, Khalil A, Global Library of Women's Medicine. DOI: 10.3843/glown.411323

[5] Purizaca M. Modificaciones fisiológicas en el embarazo. Rev Per Ginecol Obstet. 2010;**56**:57-69

[6] Carlin A, Alfirevic Z. Physiological changes of pregnancy and monitoring. Best Practice & Research Clinical Obstetrics and Gynaecology. 2008;**22**(5):801-823

[7] Ruiz-Rodríguez M,

Sánchez-Martínez Y, Suárez Cadena FC, García Ramírez JC. Prevalence and characterization of urinary tract infection in socially vulnerable pregnant women in Bucaramanga. Colombia. 2019;**69**(2):1-10. DOI: 10.15446/ revfacmed

[8] Mattuizzi A, Madar H, Froeliger A, Brun S, Sarrau M, Bardy C, et al. Infección urinaria y embarazo. EMC – Ginecología-Obstetricia. 2018;**54**(4):1-20

[9] Myers VC, Muntwiler E, Bill AH. The acid-base balance disturbance of pregnancy. The journal of biological chemestry. 1931;**98**(1):253-260

[10] Platte RO, Kim ED. Urinary Tract Infections in Pregnancy. Available from: https://emedicine.medscape.com/ article/452604-overview

[11] Werter DE, Kazemier BM, van Leeuwen E, et al. Diagnostic work-up of urinary tract infections in pregnancy: Study protocol of a prospective cohort study. BMJ Open. 2022;**12**:e063813. DOI: 10.1136/bmjopen-2022-063813

[12] Faneite P, Pérez Alonso MM, Sánchez WJ. In: González F, editor. Epidemiología y factores etiológicos. En Manejo del Parto Pretérmino. Caracas: Sociedad Venezolana de Obstetricia y Ginecología; 2012

[13] Fogazzi GB. The Urinary Sediment. An Integrated View. Third ed. Milano: Editorial Elsevier Srl; 2010. p. 251

[14] Ho ML, Liu WF, Tseng HY, Yu-Tzu Yeh YT, Tseng WT, et al. Quantitative determination of leukocyte esterase with a paper-based device. RSC Advances. 2020;**10**:27042. DOI: 10.1039/d0ra03306e

[15] Pfaller MA, Koontz FP. Laboratory evaluation of leukocyte esterase and nitrite tests for the detection of bacteriuria. Journal of clinical microbiology. 1985;**21**(5):840-842

[16] Estrada-Altamirano A, Figueroa-Damián R, Villagrana-Zesati R. Infección de vías urinarias en la mujer

*Usefulness of Urine Tests in the Prevention, Diagnosis, Treatment and Prognosis of Pathologies… DOI: http://dx.doi.org/10.5772/intechopen.109540*

embarazada. Importancia del escrutinio de bacteriuria asintomática durante la gestación. Perinatol Reprod Hum. 2010;**24**(3):182-186

[17] Myriam Ruiz-Rodríguez M, Sánchez-Martínez Y, Suárez-Cadena FC, García-Ramírez JC. Prevalence and characterization of urinary tract infection in socially vulnerable pregnant women in Bucaramanga, Colombia. Rev. Fac. Med. 2021;**69**(2):e77949. DOI: 10.15446/revfacmed.v69n2.77949

[18] Pagana K, Pagana T. Indicaciones e interpretación de resultados. In: Laboratorio Clínico. Primera edición en español ed. México: Editorial Manual moderno; 2014

[19] Prieto Valbuena JM, Yuste Ara JR. La clínica y el laboratorio. 23 edición ed. Barcelona: Elsevier editores; 2019. pp. 1160

[20] Velázquez N. La hormona gonadotrofina coriónica humana. Una molécula ubícua y versátil. Parte I. Rev Obstet Ginecol Venez. 2014;**74**(2):122-133

[21] Brajkovich I, Febres Balestrini F, Camejo M, Palacios A. Manual Venezolano De Diabetes Gestacional. Rev Venez Endocrinol Metab. 2016;**14**(1):56-90

[22] McMicking J, Lam AYR, et al, Global Library of women's Medicine, DOI: 10.3843/GLOWM.416413

[23] Vigil-De Gracia P, Olmedo J. Diabetes gestacional: conceptos actuales. Ginecología y Obstetricia de México. 2017;**85**(6):380-390

[24] Guevara-Valerio H, Mari-Zapata DD, Arévalo-Villa DI, Vargas-Aguilar DM, Etulain-González JE. Cetoacidosis diabética durante el embarazo: reporte de un caso. Ginecología y Obstetricia

de México. 2020;**88**(7):471-476. DOI: 10.24245/gom. V88i7.3547

[25] Pérez M, Pacheco M, Pérez K, Tineo N. Daño renal en pacientes preeclámpticas con criterios de gravedad. Revista de Obstetricia y Ginecología de Venezuela. 2020;**80**(3):176-186

[26] Kane SC, Wium L, et al, Global Library of women's Medicine. DOI: 10.3843/GLOWM.413253

[27] Velásquez Penagos JA, Zuleta Tobón JJ, López Jaramillo JD, Gómez Marulanda NL, Gómez Gallego J. Use of sulfosalicylic acid in the detection of proteinuria and its application to hypertensive problems in pregnancy. Iatreia. 2011;**24**(3):259-265

[28] Cravedi P, Remuzzi G. Pathophysiology of proteinuria and its value as an outcome measure in chronic kidney disease. British Journal of Clinical Pharmacology. 2013;**76**(4):516-523. DOI: 10.1111/bcp.12104

[29] Blom K, Odutayo A, Bramham K, Hladunewich MA. Pregnancy and glomerular disease a systematic review of the literature with management guidelines. Clinical Journal of the American Society of Nephrology. 2017;**12**:1862-1872. DOI: 10.2215/ CJN.00130117

[30] Jakubowski BE, Stevens R, Wilson H, Lavallee L, Brittain L, Crawford C, et al. Cross-sectional diagnostic accuracy study of self-testing for proteinuria during hypertensive pregnancies: The UDIP study. BJOG: An International Journal of Obstetrics and Gynaecology. 2022;**129**(13):2142-2148. DOI: 10.1111/1471-0528.17180

[31] Kattah A, Milic N, White W, Garovic V. Spot urine protein measurements in normotensive

pregnancies, pregnancies with isolated proteinuria and preeclampsia. American Journal of Physiology. Regulatory, Integrative and Comparative Physiology. 2017;**313**:R418-R424. DOI: 10.1152/ ajpregu.00508.2016

[32] Morikawa M, Mayama M, Noshiro K, Saito Y, Nakagawa Akabane K, Umazume T, et al. Earlier onset of proteinuria or hypertension is a predictor of progression from gestational hypertension or gestational proteinuria to preeclampsia. Scientific Reports. 2021;**11**:12708. DOI: 10.1038/ s41598-021-92189-w

[33] Jim B, Jean-Louis P, Qipo A, Garry DA, Mian S, Matos T, et al. Podocyturia as a diagnostic marker for preeclampsia amongst highrisk pregnant patients. Journal of Pregnancy. 2012;**2012**:984630. DOI: 10.1155/2012/984630

[34] Ning L, Suleiman HY, Miner JH. Synaptopodin is dispensable for Normal Podocyte homeostasis but is protective in the context of acute Podocyte injury. JASN. 2020;**31**:2815-2832. DOI: 10.1681/ ASN.2020050572

[35] Díaz Colina NG, Chiroque Parra IR, García J, Villalobos Inciarte NE. Estudio comparativo entre la índice proteína/ creatinina en una muestra de orina al azar y proteinuria en 24 horas como método diagnóstico de preeclampsia. Revista de Obstetricia y Ginecología de Venezuela. 2022;**82**(1):59-66. DOI: 10.51288/00820108

[36] Pérez Dubuc KV, Vargas Torres PA, Gil Villegas Y, Vásquez Paredes LC. Trastornos hipertensivos del embarazo: relación del índice proteína/ creatinina en orina esporádica y proteinuria en 24 horas. Revista de Obstetricia y Ginecología de Venezuela. 2022;**82**(3):297-308. DOI: 10.51288/00820305

[37] Mayrink J, Leite DF, Nobrega GM, et al. Prediction of pregnancy-related hypertensive disorders using metabolomics: A systematic review. BMJ Open. 2022;**12**:e054697. DOI: 10.1136/ bmjopen-2021-054697

[38] Monni G, Atzori L, Corda V, Dessolis F, Iuculano A, Hurt KJ, et al. Metabolomics in prenatal medicine: A review. Frontiers in Medicine. 2021;**8**:645118. DOI: 10.3389/ fmed.2021.645118

[39] Diaz SO, Barros AS, Goodfellow BJ, et al. Second trimester maternal urine for the diagnosis of trisomy 21 and prediction of poor pregnancy outcomes. Journal of Proteome Research. 2013;**12**(6):2946-2957. DOI: 10.1021/ pr4002355

[40] Cantonwine DE, Meeker JD, Ferguson KK, Mukherjee B, Hauser R, McElrath TF. Urinary concentrations of Bisphenol a and phthalate metabolites measured during pregnancy and risk of preeclampsia. Environmental Health Perspectives. 2016;**124**(10):1651-1655. DOI: 10.1289/EHP188

[41] Austdal M, Skråstad RB, Gundersen AS, Austgulen R, Iversen A-C, et al. Metabolomic biomarkers in serum and urine in women with preeclampsia. PLoS One. 2014;**9**(3):e91923. DOI: 10.1371/journal. pone.0091923

[42] Austdal M, Brettas Silva G, Bowe S, Vestrheim Thomsen LC, Haugstad Tangerås L, Bjørge L, et al. Metabolomics identifies placental dysfunction and confirms Flt-1 (FMS-like tyrosine kinase receptor 1) biomarker specificity. Hypertension. 2019;**74**:1136-1143. DOI: 10.1161/ HYPERTENSIONAHA.119.13184

### *Edited by Tomasz Jarzembowski and Agnieszka Daca*

A urinalysis is a simple test that can help find urinary tract-related problems such as kidney disease. It can also pinpoint other serious problems not so closely related to kidneys, such as diabetes, liver disease, or even various cancers.  The history of analysis of urine for diagnostic purposes is quite long. It includes the detection of microbes as etiological agents of infection and the estimation of biochemical parameters such as glucose and protein concentration. Furthermore, the increase in the number of patients suffering from chronic kidney disease or other "civilization diseases" such as diabetes, hypertension, or obesity manifests the need for effective tools for specific and sensitive diagnosis. This book summarizes the state of the art in diagnosing infectious and non-infectious diseases based on urine analysis. Additionally, it focuses on novel techniques and applications used in everyday laboratory urinalysis. The history of analysis of urine for diagnostic purposes is quite long. It includes the detection of microbes as etiological agents of infection and the estimation of biochemical parameters such as glucose and protein concentration. Furthermore, the increase in the number of patients suffering from chronic kidney disease or other "civilization diseases" such as diabetes, hypertension, or obesity manifests the need for effective tools for specific and sensitive diagnosis. This book summarizes the state of the art in diagnosing infectious and non-infectious diseases based on urine analysis. Additionally, it focuses on novel techniques and applications used in everyday laboratory urinalysis.

Published in London, UK © 2024 IntechOpen © Michael Maasen / unsplash

Advances and Challenges in Urine Laboratory Analysis

Advances and Challenges in

Urine Laboratory Analysis

*Edited by Tomasz Jarzembowski and Agnieszka Daca*


**Mariano Barbato**

Center for Religion and Modernity, 48149 Münster, Germany<EMAIL_ADDRESS>
Received: 4 March 2020; Accepted: 28 March 2020; Published: 1 April 2020

**Abstract:** Embedded in a critically adapted version of Jürgen Habermas' postsecular approach, this article analyzes empirically and evaluates normatively the role of religion in the Middle East. Integrating and adapting William Connolly's understanding of political change as power politics of becoming, the argument is that an authoritarian pluralism is evolving that, in contrast to secular nationalism and Political Islam, can be called postsecular insofar as it attempts to integrate more strata of the population into the public discourse, regardless of their religious creed but based on interreligious plurality. The Document on Human Fraternity, signed 2019 in Abu Dhabi, is a prime example of that postsecular trend embedded in power politics. The article concludes that the turmoil of the Arab Spring did not pave the way for democracy but for authoritarian and partisan versions of a postsecular public that try to accommodate the plurality of the Middle East.