This document lists and describes the normal crystals found in acidic and alkaline urine, including their appearance, characteristics, and clinical significance. In acidic urine, the normal crystals include amorphous urates, crystalline uric acid, calcium oxalate, monosodium urate, hippuric acid, and calcium sulfate. In alkaline urine, the normal crystals are amorphous phosphates, crystalline phosphates or triple phosphate, and calcium carbonate. Most of these crystals have little clinical significance when present in normal amounts, but some may indicate an increased risk of conditions like gout or kidney stone formation.
This document lists and describes the normal crystals found in acidic and alkaline urine, including their appearance, characteristics, and clinical significance. In acidic urine, the normal crystals include amorphous urates, crystalline uric acid, calcium oxalate, monosodium urate, hippuric acid, and calcium sulfate. In alkaline urine, the normal crystals are amorphous phosphates, crystalline phosphates or triple phosphate, and calcium carbonate. Most of these crystals have little clinical significance when present in normal amounts, but some may indicate an increased risk of conditions like gout or kidney stone formation.
This document lists and describes the normal crystals found in acidic and alkaline urine, including their appearance, characteristics, and clinical significance. In acidic urine, the normal crystals include amorphous urates, crystalline uric acid, calcium oxalate, monosodium urate, hippuric acid, and calcium sulfate. In alkaline urine, the normal crystals are amorphous phosphates, crystalline phosphates or triple phosphate, and calcium carbonate. Most of these crystals have little clinical significance when present in normal amounts, but some may indicate an increased risk of conditions like gout or kidney stone formation.
This document lists and describes the normal crystals found in acidic and alkaline urine, including their appearance, characteristics, and clinical significance. In acidic urine, the normal crystals include amorphous urates, crystalline uric acid, calcium oxalate, monosodium urate, hippuric acid, and calcium sulfate. In alkaline urine, the normal crystals are amorphous phosphates, crystalline phosphates or triple phosphate, and calcium carbonate. Most of these crystals have little clinical significance when present in normal amounts, but some may indicate an increased risk of conditions like gout or kidney stone formation.
1. Amorphous urates (calcium, -Precipitate upon standing in -Amorphous urates have no clinical magnesium, sodium and potassium) concentrated urine of a slightly acid significance and are distinguished from pH. amorphous phosphates on the basis of -When large quantities are present, the urine pH, their macroscopic urine sediment may appear pink- appearance, and their solubility orange to reddish brown on characteristics macroscopic examination; this appearance has been referred to as brick dust. -Microscopically, this amorphous material appears as yellow-brown small granules that can form clumps and adhere to fibers and mucous threads. -Convert to uric acid crystals with acidification with acetic acid, and will dissolve with heat (60° C) and with dilute alkali. 2. Crystalline Uric Acid - Seen in a variety of shapes, including -Large numbers of uric acid crystals rhombic or four-sided flat plates, and urates may reflect increased prisms, oval forms with pointed ends nucleoprotein turnover, especially (lemon-shaped), wedges, rosettes, and during chemotherapy of leukemia or irregular plates lymphoma. Increased quantities may -Most are colored, typically yellow or be seen with Lesch-Nyhan syndrome reddish brown. Rarely, they are and may provide circumstantial colorless and hexagonal, resembling evidence of the nature of small stones cystine. Unlike cystine, they show lodged in the ureters, especially when birefringence with radiolucent and found in conjunction polarized light. with raised serum uric acid levels. They may also herald the urate nephropathy of gout. 3. Calcium Oxalate - Dihydrates may appear at pH 6 or in - Oxalate crystals in large numbers may neutral urine. Their classic form is that reflect severe chronic renal of a small, colorless octahedron that disease or ethylene glycol or resembles an envelope methoxyflurane toxicity - Dumbbell shapes and ovoid forms - Oxaluria has come may occur into prominence as a reflection of the - Longer forms occur in calcium oxalate increased absorption of oxalates from monohydrate. Oxalate crystals are food following small bowel disease and insoluble in acetic acid. resection, notably for Crohn’s disease. - Oxaluria may also be present in genetically susceptible persons following large doses of ascorbic acid. 4. Monosodium Urate - A distinct form of a uric acid salt, - Have no clinical significance and appear as colorless to light-yellow usually are reported as “urate crystals.” slender, pencil-like prisms. - They may be present singly or in small clusters, and their ends are not pointed. - Can be present when the urine pH is acid and dissolve at 60° C. 5. Hippuric Acid - Yellow–brown or colorless elongated - Rarely seen in the urine and have prisms or plates practically no clinical significance. - They may be so thin as to resemble needles, and they often cluster together - More soluble in water and ether than are uric acid crystals 6. Calcium Sulfate - Long, thin, colorless needles or - Rarely seen in the urine and they have prisms that are identical in appearance no clinical significance. to calcium phosphate. - Found in acidic urine, whereas calcium phosphate is usually found in alkaline urine. - Extremely soluble in acetic acid 2. List and identify the normal crystals found in alkaline urine
1. Amorphous Phosphates (calcium and - have a granular appearance - Have no clinical significance and can magnesium) microscopically; unlike the former, make the microscopic examination they tend to be colorless and will difficult when a large quantity is produce a fine or lacy white precipitate present. macroscopically. - Clumps or masses can often be seen by light microscopy. Large amounts of this material may precipitate out upon prolonged standing at room temperature or in a refrigerator. - Calcium and magnesium monohydrogen phosphates are the least soluble in alkaline urine, although the dihydrogen phosphates may be soluble at a similar pH - Phosphates, in general, will dissolve in acids such as dilute hydrochloric and nitric acids and vary in solubility in acetic acid. 2. Crystalline phosphates (Triple - They are colorless, three to - Triple phosphate crystals have little phosphate/ Ammonium magnesium six-sided prisms with oblique ends clinical significance but have been phosphate) referred to as coffin lids. They may associated with UTIs characterized form colorless sheets or flakes by an alkaline pH and have been implicated in the formation of renal calculi. 3. Calcium Carbonate - These uncommon crystals are small - Present primarily in alkaline urine, and colorless, with dumbbell or calcium carbonate crystals are not spherical shapes. They may form pairs, found frequently in the urine sediment fours, or clumps. They are and have no clinical significance distinguished from other crystals/amorphous material by their production of carbon dioxide in the presence of acetic acid. 4. Ammonium Biurate - yellow-brown color and appear as - Ammonium biurate is a normal urine spheres with radial or concentric solute. These crystals occur most striations and irregular projections or frequently in urine specimens that thorns. Referred to as thorn apples, have undergone prolonged storage. they may also be seen in neutral and However, when they precipitate out of occasionally in slightly acid urine. They solution in fresh urine specimens (e.g., dissolve with heat at 60° C and with following iatrogenically induced acetic acid, reappearing as typical uric alkalinization), they are clinically acid crystals after about 20 minutes. significant, because in vivo precipitation can cause renal tubular damage. Their presence most often indicates inadequate hydration of the patient. Therefore when ammonium biurate crystals are encountered in a urine specimen, investigation is required to determine whether (1) the integrity of the urine specimen has been compromised (improper storage), or (2) in vivo formation is taking place. 5. Calcium Phosphate - Dibasic calcium phosphate crystals, - Calcium phosphate crystals are sometimes called stellar phosphates, common and have no clinical appear as colorless, thin, wedge like significance. prisms arranged in small groupings or in a rosette pattern. - Monobasic calcium phosphate crystals usually appear microscopically as irregular, granular sheets or flat plates that can be large and may be noticed floating on the top of a urine specimen. These colorless crystalline sheets can resemble large degenerating squamous epithelial cells. 3. Describe and state the significance of cystine, cholesterol, leucine, tyrosine, bilirubin, sulfonamide, radiographic dye and ampicillin crystals
1. Cystine - Cystine crystals are colorless, - Cystine crystals are among the most refractile, hexagonal plate, which important crystals identified in appear in acid urine. They are soluble urine sediment. They occur in patients in water at pH less than 2 or greater with cystinuria and may be associated than 8, and they may be confused with with cystine calculi. Confirmatory hexagonal forms of uric acid testing consists of the cyanide- nitroprusside reaction. 2. Cholesterol - Cholesterol crystals appear as clear, - Cholesterol crystals can be seen with flat, rectangular plates with notched the nephrotic syndrome and in corners. These crystals can be present conditions resulting in chyluria: the in acidic urine and, because of their rupture of lymphatic vessels into the organic composition, are soluble in renal tubules as a result of tumors, chloroform and ether. filariasis, and so on. 3. Leucine - These crystals are also rare, occurring - Present in the urine of patients with as yellow, oily-appearing spheres with overflow aminoacidurias—rare radial and concentric striations. They inherited metabolic disorders. In these are soluble in both acids and alkalis. disorders, the concentrations of these Leucine and tyrosine crystals may amino acids in the blood are high occur together; leucine may be (aminoacidemia), resulting in precipitated with tyrosine crystals if increased renal excretion. Although alcohol is added to the urine. rare, these crystals have been observed in the urine of patients with severe liver disease. 4. Tyrosine - In acidic urine, tyrosine forms fine - Present in the urine of patients with silky needles that may be arranged in overflow aminoacidurias—rare sheaves or clumps, especially after inherited metabolic disorders. In these refrigeration. These may be colorless disorders, the concentrations of these or yellow, appearing black as the amino acids in the blood are high microscope is focused. (aminoacidemia), resulting in - They are soluble in alkali (ammonia increased renal excretion. Although and potassium hydroxide) rare, these crystals have been observed and in dilute hydrochloric acid; they in the urine of patients with severe are not soluble in alcohol or ether. liver disease. 5. Bilirubin - Bilirubin crystals usually appear as - They are classified as abnormal small clusters of fine needles (20 to 30 crystals because bilirubinuria indicates μm in diameter), but granules and a metabolic disease process. plates have been observed. Always characteristically yellow-brown, these crystals indicate the presence of large amounts of bilirubin in the urine. Bilirubin crystals are confirmed by correlation with the chemical examination, that is, the crystals can be present only if the chemical screen for bilirubin is positive. - Bilirubin crystals only form in an acidic urine. They dissolve when alkali or strong acids are added. 6. Sulfonamide - These crystals may be seen in urine of - These crystals could be seen in the acid pH and may take on various urine of patients on sulfonamide morphologies, depending on the form therapy who were inadequately of drug involved. They may be seen as hydrated. This could result in renal yellow-brown sheaves of wheat with tubular damage if crystal formation central bindings, striated sheaves with occurred within the nephron. eccentric bindings, rosettes, Currently, sulfamethoxazole (Bactrim, arrowheads, petals, needles, and round Septra) is seen with some regularity. forms with radial striations. They are occasionally colorless. Confirmatory testing is by the diazo reaction. - Sulfa crystals are not as frequently found in urine, especially when urine is examined at 37° C. 7. Radiographic Dye - Crystals of radiographic contrast - They may be found in urine of acid pH media following retrograde shortly after intravenous radiographic administration appear as colorless, studies (particularly if the patient has long, rectangular needles that occur not been well hydrated) singly or clustered in sheave; when - The presence of radiographic crystals administered intravenously, they should correlate with a high specific appear as flat, elongated rectangular gravity (>1.040). plates. 8. Ampicillin - Ampicillin may crystallize in the urine - Present in acidic urine, ampicillin under conditions of high dosage. These crystals indicate large doses of crystals appear in urine of acid pH as ampicillin and are rarely observed with long, fine, colorless structures . They adequate hydration. may form coarse sheaves after refrigeration.
REFERENCES. Fundamentals of Urine and Body Fluids by Nancy Brunzel
Graff’s Textbook of Urinalysis and Body Fluids
Henry’s Clinical Diagnosis and Management by Laboratory Methods, 23 rd ed.
4. Differentiate between actual sediment constituents and artifacts