MICROSCOPIC URINALYSIS URINARY SEDIMENTS © integral part of the urinalysis (UA). © Sediment findings often are necessary for the proper interpretation of results of the physicochemical portion of the UA © Detect and identify insoluble materials in the urine, Linilations © Least standardized © Time consuming © Expensive © Requires Technical expertise * The decision to perform microscopic examinations should be made by each individual laboratory based on its specific patient population.” -cLSE ins cna dvation © Fresh or adequately preserved © Mid-stream clean catch © First morning specimen © Thoroughly mixed VOLTUME: © 10-15 mL © Indicate if lesser volume is used © Correct for volumes Syocines Codsifugaion © Sminutes © 400 RCF (relative centrifugal force) © Braking mechanism is not recommended SEDIMENT PREPARATION © 05-10mL © Aspirate off the supematant © Thorough resuspension of the sediment SEDIMENT VOLE tM © 20 ul (0.02 ml) © Cover slip overflow of sediment not allowed BY © Centrifugal force - how many times greater than gravity - expressed as relative centrifugal force (RCF) or g- depends on three variables i. speed- expressed as revolutions per minute (rpm) **related to RCF by the following equation: ROF = 1.118 x 10° x rx (rpm) ii, mass i. radius(e)- measured from the center of the centrifugal axis to the bottom of the test tube shield Contitnnls of sine tdi © Organized sediment - biological source RBC wee Epithelial cells Fats Casts Bacteria Yeast Fungi Parasite spermatozoa © Unorganized sediment chemical source * Normal acid crystals * Normal Alkaline crystals + Abnormal crystals of metabolic origin * Abnormal crystals of iantrogenic origin Rat Blood Cots (RBO © Smooth, non-nucleated, biconcave disk © 7 um in diameter © Examined under HPO. © Reported as average in 10 HPFs Variations: 1. Crenated - found in concentrated urine. 2. Ghost cells - cell membrane found in dilute urine 3. Dysmorphic - cells of varying sizes, have cellular protrusions or are fragmented Normal and Crenated R&CNormal and Dysmorphic RBC Clinical Significance © Damage to the glomerular membrane © Vascular injury within the genito-urinary tract © Increased following strenuous exercise © Contamination with menstrual blood GROSS HEMATURIA: © Advanced glomerular damage © Trauma damaging vascular integrity © Acute inflammation and infection © Coagulation disorder Wate Broad Calle (Meets) Larger than RBCs measuring 12 um in diameter. Predominantly neutrophils Contains granules and multi-lobed nuclei Reported as average number per 10 hpf “Glitter Cells" - disintegrated neutrophils Easily lyses in dilute alkaline urine o000000Chrcamonan WBC Evinylite ~ associated with drug induced interstitial nephritis, UTI and renal transplant rejection © Reported as apercentage in 100 to 500 WBC © 1% eosinophil is significant © Preferred stain - Hansel omnucese Cite ~ increased in the early stages of transplant rejection © Appears vacuolated and contains inclusions © Diagnosed by cytocentrifugation and Wright's stain Clinical Significance Pyuria - increase in urinary WBCs © Indicates: -infection or inflammation in the genitourinary system -Bacterial infection: pyelonephritis, cystitis, prostatitis and urethritis -Non-bacterial disorders - glumerulonephritis, LE, Interstitial nephritis and tumors Evutetict Cll © Represents the normal sloughing of old cells © Clinically insignificant in small numbers © May be contamination from the genitalia© Three types are seen in urine classified according to their site of origin in the genitourinary tract. ~ Squamous epithelial cells - Transitional epithelial (Urothelial) cells, ~ Renal Tubular Epithelial Cells Sunmess thei elle Largest cells found in the urine sediment Contains abundant cytoplasm with a prominent nucleus Originates from the linings of the vagina and female urethra and the lower portion of the male urethra. No clinical significance Usually increased in females Reported in words as rare, few, moderate or many o0°0 ooo Cue Cotte © Indicates infection vaginal infection with Gardnerella vaginalis © Squamous cells covered with the bacteria - =annstna Eithtat Cot Catia) © Smaller than squamous cells © Appears in several forms (polyhedral, spherical, caudate) due to its ability to absorb water. © Originates from the lining of the renal pelvis, calyces, ureters and bladder and the upper portion of the male urethra © Noclinical Significance © Increased in invasive urologic procedures such as catheterization © Presence of vacucles and irregular nuclei may indicate viral infection or malignancy & “ee ” Renal Fadrctew Epithet Ceths © The most clinically significant of the epithelial cells. © Morphology varies depending on the site of origin PCT - largest of the RTE, rectangular, coarsely granular cytoplasm. DCT - smaller, round or oval, with eccentrically placed round nucleus Collecting ducts - cuboidal, never round, eccentrically placed nucleus, one side is straight, appears in sheetsRTE Clinical Significance © Increase indicate necrosis of the renal tubules = exposure to heavy metals - drug induced toxicity ~ hemoglobin and myoglobin toxicity - viral infection -pyelonephritis - allergic reaction ~ malignant infiltration -salicylate poisoning acute allogenic transplant rejection Coat Jot Butine © RTE cells that absorb lipids present in the glomerular filtrate © Highly refractile © Seen along with free-floating fat droplets © Stains well with Sudan III and Oil Red O © Composed of triglycerides, neutral fats and cholesterol © “Maltese Cross” - observed in the presence of cholesterol under polarized lightMaltese Cross a Unique to the kidney Most difficult to recognize and most important sediment Represent a biopsy of the tubules Must be observed under subdued light because of the low refractive index of the cast matrix Reported as the average number in 10 Ipfs Disintegrates in dilute alkaline urine. e00000n Compasition of Casts © Major constituent: Tamm-Horsfall protein © The glycoprotein gels easily under conditions of urine acidity and the presence of sodium and calcium © Width of the cast depends on the size of the tubule stasis, Cot Zomution © Formed in the lumen of the DCT and collecting ducts Loop of HenleLyaline Cot The most commonly seen cast in the urine Consist almost entirely of Tamm-Horsfall protein Colorless, homogenous, non-refractive, semi-transparent 0-2/lpf is normal Seen in strenous exercise, dehydration, heat exposure, and emotional stress Increased in acute glomerulonephritis, pyelonephritis, chronic renal disease and congestive heart failure 000000 Hyaline CastRBC Cost Indicates bleeding within the nephron Primarily associated with damage to the glomerulus. Also associated with proteinuria and dysmorphic RBC Orange-red in color Dirty brown cast indicates hemoglobin degradation and associated with acute tubular necrosis, o©0000 Red Blood Cell CastWBC Corts ° ° ° ° Indicates infection or inflammation within the nephron, Associated with pyelonephritis and differentiates upper UTI from lower UTI Also seen in acute interstitial nephritis and glomerulonephritis. Appears granular and multilobed White Blood Cell CastEvitheiad Celt Case © Contains RTE cells © Indicates advanced tubular destruction © Seen in heavy-metal and drug induced toxicity, pyelonephritis. | infections, allograft rejections and Sati, Cats © Associated with oval fat bodies and free fat droplets in cases of lipiduria © Indicates nephrotic syndrome, toxic tubular necrosis, DM and crush injuries © Highly refractile, confirmed with Sudan III and Oil Red O using polarized lightMise Caltulon Casts © Contains more than one type of cell © Usual combinations: WBC and RBC in glomerulonephritis, WBC and RTE or WBC and bacteria in pyelonephritis, Makes identification difficult Grande Cats © May appear finely of coarsely © Non-patholegic increase in strenuous exercise © In diseases, it indicates disintegration of cellular castsGranular Cast Wasy Caste © Represents extreme urine stasis indicating chronic renal failure. © Presents brittle, highly refractile cast matrix due to disintegration of hyaline and other cellular components of the cast © Appears fragmented with jagged edges and notches on their sidesBrood Coste Also referred to as renal failure casts Represents extreme urine stasis Indicates destruction of the tubular walls Commonly of the granular and waxy types. usCot Zoomaion Cellular Coarsely granular cast Renal tubules e Coste Rare incorporation of other structures in the urine sediments Pigmented Casts - hemoglobin, myoglobin and certain drugs Hemosiderin casts Crystal casts - urates, calcium oxalates and sulfonamides Gplindrie © Resemble casts but have one end that tapers toa tail © Found in conjunction with casts and have. same significanceMucus Thecods © Long thin waxy threads, very transparent © Can be found in small number in normal urine © Increased numbers indicate inflammation or irritation of the urinary tract Bactovia © Not normally seen in urine © Results from vaginal, urethral, external genitalia or specimen container contamination © Presents as cocci or bacilli © Usually motile © May Indicate UTI if seen in freshly voided urine and correlated with wees Gat © Small, refractile, oval structures which may show budding © Insevere in fections, mycelium may be seen © Most common: Candida albicans© Seen in DM, immunocompromised patients and women with vaginal moniliasis © Accompanied by WBCs Sang: © Insevere infections © May include appearance of mycelium Pracasites © Most frequent: Trichomonas vaginalis - pear shaped flagellate with undulating membrane © In fresh wet preparations, usually motile with rapid darting movements© Other parasites: Schistosoma haematobium, Enterobius vermicularis, other parasite contaminants from the feces T. vaginalis S. haematobium E. Vermicularis Spermatoeeet© Oval, slightly tapered heads and long flagella like tails, usually non-motile © Seen in urine of both female and male after intercourse and in male urine after masturbation and nocturnal emission © Not clinically significant except in cases of male infertility and retrograde ejaculation © Also important in medico-legal cases Ceanany Coys © Formed by the precipitation of urine solutes © Rarely of clinical significance © Reported in words © Identified in order to detect the few abnormal crystals Castel Jermotion © In vivo factors include: the concentration and solubility of crystallogenic substances contained in the specimen, © the urine pH © the excretion of diagnestic and therapeutic agents. © Invitro factors include: temperature (solubility decreases with temperature), © evaporation (increases solute concentration), © urine pH (changes with standing and bacterial overgrowth). ovens Clot © Amorphous urates appear as aggregates of finely granular material without any defining shape © Amorphous urates (Na, K, Mg, or Ca salts) tend to form in acidic urine © May have a yellow or yellow-brown color. © Common in refrigerated specimens wit pink sedimentstod © May appears as Rhombic, foursided flat planes, wedges, and rosettes © Usually yellow-brown but may appear colorless © Highly birefrigent under polarized light (© Increased in high levels of purines and nucleic acids © Seen in patients with leukemia undergoing chemotherapy, Lesch-Nyhan syndrome and gout Catan Cualate Deydts © Calcium oxalate dihydrate crystals typically are seen as Ee . colorless squares whose corners are connected by intersecting lines (resembling be an envelope). _ © They can occur in urine of any a pH. © The crystals vary in size ; from quite large to very ‘small is © Insome cases, large numbers of tiny oxalates may appear as amorphous unless examined at high > & magnification, 4 a© Increased in high intake of oxalic acid and ascorbic acid Cataien Ctate enaydeate Less frequently seen Oval or dumbbell shaped Birefrigent Indicates ethylene glycol poisoning e000 wal Captls ion meat halve wie Amorphous phosphate Triple Phosphate. Calcium Phosphate Calcium Carbonate ‘Ammonium Biurate, 00000 obmanhous Phosphates © Morphologically resemble amorphous urates © Increased in refrigerated sample but gives a white color © Can be differentiated from urates by the pH of the urine and its non-dissolution on warmingLainte Phamphte, Sinute, etnmeriin Moguasiun yhanphate © appear as colorless, 3-dimensional, prism-like crystals ("coffin lids"). © Occasionally, they instead resemble an old-fashioned double-edged razor blade © Birefrigent on polarized lightCots Phahate ° ° ° ° ° Colorless ‘Shape: long, thin prisms with one pointed and arranged as rosettes or clusters of needles Thin irregular plates that float on surface of urine Associated with renal calculi Dissolves in dilute acetic acid ‘© May be confused with sulfonamide crystalCoteinme Canbemote © Calcium carbonate crystals usually appear as large yellow-brown or colorless spheroids with radial striations, © They can also be seen as smaller crystals with round, ovoid, or dumbbell shapes © Liberates gas on addition of acetic acid obmonanian Biwate Color: yellow to brown ‘Shape: Spherical bodies with long irregular spicules Often described as thorn- apple Associated with the presence of ammonia from urea-splitting bacteria Soluble in acetic acid and Heat e0000 bhromncl Cine enptls of Matobalic Origin © Seen inacidic to neutral urine © Requires chemical confirmation = Cystine “Tyrosine-Leucine Cholesterol - Bilirubin Colorless, refractile, hexagonal plates that are often laminated Seen in patients with cystinuria Disintegrates in alkaline urine Soluble in ammonia and dilute HCI Confirmed by the cyanide nitroprusside reaction 00000 Fipasss © Colorless, fine, silky needles arranged in sheaves or clumps © Seen in hereditary tyrosinosis, casthouse urine disease and with leucine in massive liver failure. © Confirmed by the nitrosonaphthol test or HPLCLows © Yellow, oily looking spheres with radial and concentric striations © Extremely rare © Seen in severe liver damage with tyrosineChotestevat Color: transparent ‘Shape: regular to irregular flat plates with one corner notched out, may be single or in larger numbers Most often found after refrigeration Indicates Excessive tissue breakdown Seen in nephritis and nephritic syndrome. Soluble in chloroform oo e000 Batra © Bilirubin crystals tend to precipitate onto other formed elements in the urine © fine needle-like crystals can form on an underlying cell. This is the most common appearance of bilirubin crystals.© cylindrical bilirubin crystals can form in association with droplets of fat, resulting ina “Flashlight” appearance. This form is less commonly seen © Seen in Obstructive jaundice © Bilirubin must be present in urine Misra Cpt of Didrptt aig © Caused by increased amount of drugs© Important because of the likelihood of renal damage and bleeding leading to renal failure ~Sulfonamides -Ampicillin Radiographic contrast media Sulfumanides © Color: brown to yellow © Shape: needle-like shapes seen in bundles or sheaves; Stacks of wheat © Common forms: sulfamethoxazole, acetylsulfadiazine and sulfadiazine eile © Long, thin, colorless needles in acidic urine © Very rarely seen © Seen in Administration of large parenteral doses oe ‘Radiographic amt media Color: opaque , appear dark and thick Shape: pleomorphic needles, single or sheaves May be mistaken for cholesterol crystals Significant in elderly patients Intravenous injection for radiography Can appear up to 3 days after injection e0000 Cssrpcaras oD aapaar © Usually easy to see © Causes distraction on the observer - Starch Fibers -Air bubbles-Oil droplets ~Glass Fragments ~ Stains - Pollen grains - Fecal contamination