Symptoms and signs of urinary

tract diseases

Tbilisi referral hospital, Tbilisi, Georgia

Nephrologist
Nino Maglakelidze
 How do patients with kidney disease typically present?

Patient with kidney disease typically present in several ways:

Edema

New onset hypertention

Abnormal laboratory studies (elevated blood urea nitrogen BUN,

and serum creatinine, decreased estimated glomerular filtration rate,
or abnormal serum electrolyte values)

Asymptomatic urinary abnormalities (gross or microscopic

hematuria, proteinuria, microalbuminuria)

Changes of urinary frequency or problems with urination (polyuria,

nocturia, urgency)
 Patient with kidney disease typically present in several
ways:

Nonspecific symptomatologies (nausea, vomiting, malaise)

Ipsilateral flank pain - nephrololithiasis

Incidental discovery of anatomic renal abnormalities on routine

imaging studies (congenital absent, or ptotic kidney, asymmetric
kidneys, angiomyolipoma, renal mass, polycystic kidney);
 Familial diseases which are characterized
by kidney involment

Polycystic kidney disease

Focal segmental glomerulosclerosis (linked to
chromosome 11)
Fabry’s disease
Alport’s syndrome
Herditary interstitial Kidney disease (HIKD, linked
to chromosome 1)
Cystinuria
 Clinical signs and symptoms of patients with CKD:
Loss or decreased appetitive
Easy fatigability
Generalized weakness
Involuntary weight loss (resulting from cachexia) or gain (resulting
from fluid retention)
Alteration in mentally (lethargy, coma, difficulty concentrating)
Nausea, vomiting, dyspepsia
Metallic taste
Generalized itching or pruritus
Seizures
Difficulty breathing
Edema
Intractable hiccups
,,Frothy” appearance of urine
Decreased sexual interest
Restless legs
 Clinical signs and symptoms of patients with CKD:

Elevated blood pressure

Pallor (from anemia)

Volume overload (jugular venous distention, peripheral edema,

pulmonary edema, anasarca)

Friction rub (pericarditis)

Asterixis and myoclonus

 Extrarenal manifestations associated with kidney
diseases

Dermatologic:

Xerosis or dryness of skin – hemodialysis patients

Pruritus and itching – ESRD patients can lead to excoriations;

Ecchymoses – associated with platelet dysfunction

petechiaen rash – cryoglobulinemic glomerulonephritis

 Extrarenal manifestations associated with kidney diseases

Arthritis:

Lupus nephritis

Henoch-Schonleine purpura

Cryoglobulinemia

Amyloidosis

Gout nephropathy
Extrarenal manifestations associated with kidney diseases

Hemoptysis

Goodpasture’s syndrome –anti GBM disease

Henoch-Schonleine purpura
Pauci-immune crescentic glomerulonephritis
Wegener’s granulomatosis
Churg-Strauss syndrome
Microscopic polyarteritis
Cryoglobulinemia
Lupus nephritis with pneumonitis
Volume overload (congestive heart failure, mitral stenosis)
Extrarenal manifestations associated with kidney diseases

Hearing loss:

Alport’s syndrome

Abdominal discomfort :

Henoch-Schonlein purpura
Cryoglobulinemia
Microscopic polyarteritis

Intracerebral aneurisms:

Autosomal dominant polycystic disease

 Changes in micturation:

Polyuria

Nocturia

Urgency

Dysuria

Anuria, oliguria
 Changes in micturation:

Polyuria – the excessive passage of urine at least 2.5 l per day for
an adults;

Nocturia – nycturia is defined as the complaint that the individual

has to wake up at night once or more times for voiding;

Urgency – is characterized by urine urgency and frequency,

sometimes associated with nocturia and incontinency;

Dysuria- Pain during urination or difficulty urinating; Dysuria is

usually caused by inflammation of urethra or as a result of infection.
 Changes in micturation:

Anuria – nonpassage of urine, in practice is defined as passage of

less than 100 ml of urine in a day;

Oliguria – is defined as urine output is less than 1 ml/kg/h, less

than 0.5ml/kg/h in children and less than 400ml a day in adults;
 Urinalysis

Physical characters of urine

Urine color:

Normal urine color can vary from pale or light yellow to dark yellow;

Urine chemical composition and urine concentration ability influence

urine color.

In volume depleted individuals urine concentration tends to

be elevated, giving urine dark-yellow urine.

In diabetes insipidus urine concentration ability is decreased,

making urine color light yellow;
Urine color and turbidity:

The degree of turbidity and cloudiness is usually influenced by

excess amounts of cellular debris and casts, It can be also secondary
affected to excess proteinuria and or crystals or contamination with
vaginal discharge.

Urine pH:
Normal urine pH ranges between 4.5 and 8.0;
In a normal individual the daily average endogenous acid
production is 1 mEq/kg; this induces H ion excretion and keep urine
pH low
Urine specific gravity :

The urine specific gravity ranges between 1. 005-1.020

Specific gravity reflects the ability of kidney to concentrate urine

In patients with impaired urinary concentrating ability (acute

tubular necrosis, sickle cell nephropathy, diabetes insipidus ) the
specific gravity tends to be low;

Specific gravity also reflects patients hydration status;

Urinalysis - the formed elements of the urinary sediment

Cells

Erythrocytes - RBC

The diameter of erythrocytes 4.0 to about 10 µm;

RBCs are typically uniform and round;

RBC diameter is Influenced by specific gravity

If specific gravity is <1010, Erythrocytes undergoes lyses
Erythrocytes - RBC in urine
 Erythrocytes - RBC

Refractivity index of erythrocytes varies according to their

haemoglobin content
If refractivity is low the erythrocyte is very discernible and
Only thin cell membrane is identifiable; (Ghost cell)
 Erythrocytes - RBC
Dysmorphic erythrocytes

RBCs have abnormal shape;

The change in morphology is manifested by budding and segmental

lost of membrane;
 Erythrocytes- RBC
Acantocytes

Ring-shaped RBCs
With vesicle shaped protrusions
Best seen by phase -contrast microscopy;
 Urinalysis – Urinary sediment microscope

WBC

Three types of WBC can be found in the urine:

Neutrophils,

Eosinophils and

lymphocytes;
 Urinalysis – Urinary sediment microscope

Neutrophiles:

Round granular cells

Diameter ranges between 7.0 to 15 µm

Urine osmolality and specific gravity affect diameter and

morphology of neutrophiles;

In diluted urine the cell is larger and swollen and both nucleus and
cytoplasmic organelles are easily identifiable.
 Urinalysis – Urinary sediment microscope

Neutrophiles
 Urinalysis – Urinary sediment microscope

Neutrophiles

Neutrophils can be detected in the following diseases:

Urinary tract infection

Acute and chronic interstitial nephritis,

Polycystic kidney disease

Urologic disorders;
 Urinalysis – Urinary sediment microscope

Eosinophils:

Eosinophols have a bilobar nucleos

Well defined granules, which occupy the entire cytoplasm

With May-Grunwald-Giemsa staining is purple color

With Wright’s stain granules range from deep blue to faint pink
 Urinalysis- Urinary sediment microscope
Eosinophils

With May-Grunwald-Giemsa staining is purple color

 Urinalysis – Urinary sediment microscope

Eosinophils:
With Wright’s stain granules range from deep blue to faint
pink
 Urinalysis – Urinary sediment microscope

Eosinophils can be seen:

Specific marker of interstitial nephritis

Urinary tract infection

Prostatitis

Extracapillary glomerulonephritis

Henoch – Schonlein purpura

 Urinalysis – Urinary sediment microscope

Lymphocytes:

Detectable only by phase contrast microscope

Small round cell

With a large nucleus

And a very thin pale cytoplasmic rim

Lymphocytes can be detected:

•Early and sensitive marker of acute rejection in renal allograft

recipients
 Urinalysis – Urinary sediment microscope

Lymphocytes:
Urine culture:

A significant number of leukocytes (>10/microL or 10,000/mL) in urine

is indication for urine culture.

Hemocytometry is the preferred method of microscopic assessment

for pyuria.

White blood cell casts in the urine are indicative of kidney

inflammation, which may reflect pyelonephritis or other renal
conditions.
Urine culture:

When the patient is asymptomatic, finding various bacterial strains

should not be considered a UTI.

In a symptomatic patient who has complaints consistent

with cystitis and bacteriuria, but does not have pyuria, a repeat urine
sampling should be done.

If the pattern is the same, with bacteriuria but no pyuria and with
persistent symptoms of urethral inflammation, this is consistent with
the "acute urethral syndrome" and antibiotic treatment should
generally not be undertaken at that point.
Definition of a positive culture

In asymptomatic patients, the standard threshold for bacterial

growth on a midstream voided urine that is reflective of bladder
bacteriuria as opposed to contamination is ≥105 colony forming
units (CFU)/mL.

However, in symptomatic women with pyuria, lower midstream

urine counts (ie, ≥102/mL) have been associated with the presence
of bladder bacteriuria.

Thus, in such instances, the findings of a colony count <105

but ≥102/mL may still be indicative of a UTI.
Macrophages

Urinary macrophages are roundish cells with very variable

diameter from 13 to 95µm
Variable appearance
Macrophages contain one or more nuclei, which can be either in
central or peripheral
There are four different types macrophages :
Granular macrophages, whose cytoplasm contains variable
amounts of granules
Vacuole-forming macrophages, whose cytoplasm contains
variable numbers of vacuoles
Macrophages with phagocytic activity, whose cytoplasm contains
bacterial debris, cell fragments, destroyed erythrocytes, etc
Macrophages with a homogeneous or hazy appearance, whose
cytoplasm does not contain granules or other particles;
Macrophages are detected by phase contrast microscope in
kidney transplant patients with BK polyomavirus infection,
these are ,,decoy cells”.
Renal tubular epithelial cells

The different segments of the renal tubules are lined by

different types of epithelial cells;

They differ with respect to shape (flat, cuboide, or column)

Contours (with or without brush border, with few or many

microvilli)

Cytoplasmic organelles (scarce or abundant)

Location of nucleus (basal, central and apical);

Renal tubular epithelial cells
 Renal tubular epithelial cells

Renal tubular epithelial cells are detected :

Acute interstitial nephritis

Acute renal rejection

Acute tubular necrosis

 Squamoues epithelial cells

The largest cells in the urinary sediment ranges from 17 to 118µm

Shape are quadrangular to polygonal

Have broad cytoplasm containing few granules

And small central nucleus

Squamoues epithelial cells are found in female patients with Candida

and Trichomonas vaginalis;
Squamous epithelial cells
Lipids in Urine

In the urine sediment lipids appear as:

Free lipid droplets

Oval fat bodies

Fatty casts

Cholesterol crystals
Lipids in Urine

•Free lipid droplets, isolated or in aggregates, appears as translucent

round particles of very variable size, with a bright yellow color.

•,,Oval fat bodies” defines macrophages or tubular epithelial cells.

Intracellular lipid particles can be in small amounts, in which case the
underling cellular details can be seen.

•Fatty casts are cylinders which contains lipid droplets in their matrix

•Cholesterol crystals are thin, colorless and transparent plates with

well defined edges;

Lipiduria can be found in nephrotic syndrome.

Casts

Casts are cylindrical elements of variable diameter and length

which form in distal tubules and collecting ducts of kidneys;

Types of casts:

Hyaline casts

Granular casts

Waxy casts
Hyaline casts

Hyaline casts contain Tamm-Horsfall glycoprotein;

There are several morphological types of hyaline casts:

compact, febrile, convoluted or wrinkled;

Hyaline casts can be found in normal subjects, also can be

detected in individuals without kidney diseases:

•physical exercise

•fever and

•dehydration;
Granular casts

Typical granular casts have their surface covered by granules which

vary in number and size. Granules can be fine, coarse, clear, dark or
pigmented;

Granular casts can be detected in glomerulonephritis and renal

tubular necrosis.
Waxy casts

Waxy casts derive their name from their appearance, which is

reminiscent of melted wax. They have a high refractive index, dark
color, broad diameter and hard, frequently indented and cracked edges.

Waxy casts are seen acute and chronic renal failure.

RBC casts

The RBCs within the cast may be so tightly packed that the
matrix of the cast can hardly be seen and individual erythrocytes can
hardly discernible.

The RBC within the casts can have a normal or reduced

haemoglobin content and

Can be either isomorphic or rarely dysmorphic

even found acanthocytes trapped within the cast matrix.

RBC casts always indicates glomerular bleeding and found in

glomerulonephritis.
RBC casts
WBC casts

WBC casts can contain variable amounts of leukocytes, from few

to so many that the matrix is totally masked.

WBC can be well preserved or degenerated, in which they are

hardly distinguishable from renal epithelial cells;

WBC casts can be detected:

•acute bacterial infection

•Lupus nephritis
•Acute interstitial nephritis
Renal tubular epithelial cell casts

Epithelial casts contain variable amounts of renal tubular epithelial cells,

these cells are identical to RTECs, and have nucleus and a granular
cytoplasm.

Renal tubular epithelial cell casts are detected epithelial cell damage,
renal tubular necrosis;
 Thank you for
Thank you for your attention
your attention