[1] LESSON 6: URINALYSIS—MICROSCOPIC EXAMINATION OF URINE Flashcards
May indicate the presence of certain sediments
Color
Pathologic or non-pathologic causes of turbidity
Clarity
Blood
RBCs, RBC Cast
Protein
Casts, cells
Nitrite
Bacteria, WBCs
LE
WBCs, WBC Casts, bacteria
Visualization of elements with low refractive indices
Phase-Contrast Microscopy
Phase-Contrast Microscopy elements
hyaline, mixed cellular cast, MT, Trichomonas
Interference-Contrast Microscopy Types
A. Nomarski (Differential)
B. Hoffmann (Modulation)
Bright-Field microscopes can be adapted
Interference-Contrast Microscopy
3-D microscopy image and layer-by-layer imaging of a specimen
Interference-Contrast Microscopy
SternheimerMalbin components
(CV + Safranin O)
Enhances nuclear detail
0.5% Toluidine Blue
% Acetic acid
2%
Hansel Stain components
Eosin Y + Methylene blue
Stains TAG and neutral fats (orangered)
Lipid stains
Lipid stains components
ORO and Sudan III
Urinary eosinophils
Hansel Stain
Crystals (normal) Moderate
5-20
Bacteria
Rare
Bacteria few
10-50
Casts Quantitated
Per LPF
RBCs
Per HPF
WBCs Quantitated
Per HPF
SEC Frequency
Rare, Few, Moderate, Many
TEC, yeasts Frequency
Rare, Few, Moderate, Many
RTE cells Frequency
Average
Abnormal crystals and casts Frequency
Average
Red blood cells
Normal value range: _________/HPF
Red blood cells
Hypertonic urine = __________________________
CRENATED
Red blood cells
Hypotonic urine = __________________________
Glomerular bleeding/damage= __________________________
RBC CASTS
White blood cells
Normal value range: _______
0-5 /HPF
granules undergo Brownian Movement
GLITTER CELLS
Neutrophils
*clinically insignificant
Glitter Cells
Eosinophils
o Normal value range: __________
<1% Toluidine Blue
White blood cells Stain
Sternheimer-Malbin Stain
Glitter cells stain color
(Pale blue)
Leukocytes stain color
(Pale pink)
Eosinophils
Clinically significant: __________ (associated with drug-induced interstitial nephritis)
Mononuclear cells (___________________)
LYMPHO, MONO, MACS, HISTIOCYTES
Largest cell
Squamous epithelial cell
Squamous epithelial cell size
30-40 um
_______________: SEC studded with Gardnerella vaginalis; associated with bacterial vaginosis
CLUE CELLS
Transitional epithelial cell (____________)
UROTHELIAL
Spherical, polyhedral or caudate with centrally located nucleus
Transitional epithelial cell
o Most clinically significant epithelial cell
Renal tubular epithelial (RTE) cell
Oblong or round to oval or rectangular and contain an eccentric nucleu
Renal tubular epithelial (RTE) cell
Renal tubular epithelial (RTE) cell
> 2 RTE/HPF indicates ___________________
TUBULAR DAMAGE
Renal tubular epithelial (RTE) cell
Variations
i. _______________
ii. _______________
OVAL FAT BODIES
BUBBLE CELLS
Seen in lipiduria (i.e. nephrotic syndrome)
OVAL FAT BODIES (Lipid-containing RTE cell)
Lipid-containing RTE cell Identification
Lipid Stains
Polarizing Microscope
Lipid Stains
TAG and Neutral fats
Polarizing Microscope (MALTESE-CROSS)
OVAL FAT BODIES
o UTI: ___________________ MOST FREQUENTLY ASSOCIATED
Bacteria
Most common cause of UTI: _________________________
ENTEROBACTERIACEAE (GRAM NEG)
Most frequent parasite encountered in urine urine
Trichomonas vaginalis
Pear-shaped flagellate (RAPID DARTING motility)
Trichomonas vaginalis
Trichomonas vaginalis
Method of reporting: ___________
RARE, FEW, MODERATE, MANY PER HPF
associated with bladder cancer
Schistosoma haematobium ova
Specimen: 24hr unpreserved urine
Schistosoma haematobium ova
Most common fecal contaminant
Enterobius vermicularis
True yeast infection: ____________________
WITH WBC
= seen in DM patients and IMMUNOCOMPROMISED
Candida albicans
Mucus thread
o Major constituent: ________________
TAMM- HORSEFALL PROTEIN (UROMODULIN)
Factors that favors cast formation
Low pH: ______________________
- Urine stasis
- High salt concentration
- Low pH
CASTS (CYLINDRURIA)
Major constituent: _______________ produced by _______
UROMODULIN
RTE CELLS
Beginning of all casts
Hyaline cast
Hyaline cast
Normal Value: ___________
0-2 PER LPF
Physiologic: Emotional stress, exercise, dehydration, heat exposure
Pathologic: Glomerulonephritis, pyelonephritis, CHF
Hyaline cast
Nephron bleeding
RBC cast
PER LPF
Glomerulonephritis, proteinuria, dysmorphic RBCs
RBC cast
Inflammation within the nephron
WBC cast
Granules are derived from the lysosomes of RTE cells during normal metabolism
Granular casts
Granular casts
Glomerulonephritis, Pyelonephritis, Stress, _______________
Final degenerative form of all types of casts
Waxy cast
Chronic renal failure
Waxy cast
Broad cast
Aka ____________________
Factors affecting precipitation _________________ _________________ _________________
URINARY CRYSTALS
usually reported as ________/____
RARE, FEW, MODERATE, MANY PER LPF
URINARY CRYSTALS
abnormal crystals may be averaged ___
AVERAGE or HIGH
Brick dust / yellowbrown granules
Amorphous urates
frequently encountered as pink sediment (uroerythrin)
Amorphous urates
Heat and Alkali fluid
Amorphous urates
Ethylene glycol poisoning
CaOx
mistaken as RBC; suggests possibility of a calculus
CaOx
“cigarettebutt”
Calcium sulfate
Heat with HAc
Ammonium biurate
“magnesium phosphate crystals”
Calcium phosphate/apatite
“Magnesium ammonium phosphate” “coffin lid” “fern leaf”
Triple phosphate
Gas from HAc
Calcium carbonate
Mistaken as Uric acid crystals
Cystine
Cystinuria Cystinosis
Cystine
birefringence
Cystine
Rectangular plates w/ notched edges
Cholesterol crystal
(staircase pattern)
Cholesterol crystal
Nephrotic syndrome (lipiduria)
Cholesterol crystal
seen in conjuction with fatty casts and OFB
Cholesterol crystal
*heavy proteinuria
Cholesterol crystal
Chloroform
Cholesterol crystal
“sheaves of wheat”
Sulfonamide
“petals”
Sulfonamide
Mistaken as calcium phosphates
Sulfonamide
Soluble in HAc while positive with Lignin and Diazo rxn
Sulfonamide
Lignin Test (Old Newspaper test) = urine + 25% HCl=
yellow color (+)
Colorless needles that form bundles after refrigeration
Ampicillin
precipitates with tyrosine after the addition of alcohol
Leucine
Liver disorder
Leucine
Colorless to yellow needles in clumps or rosette
Tyrosine
Liver disease (more common that leucine)
Tyrosine
Clumped needles or granules with HAc, HCl, bright yellow color (+ in bilirubin rgt strip)
Bilirubin
Liver disease (most common)
Bilirubin
NaOH, ether, chloroform
Bilirubin
[?] mL of urine
10 to 15
Centrifuge at [?]
400 RCF for 5 mins
Decant urine ((?) remains)
0.5-1 mL
Transfer [?] to glass slide with 22 x 22 mm coverslip
20 uL
Examine (?)
10 LPF and 10 HPF
Quantitative measure of formed elements using a hemocytometer
Addis Count
Addis Count
Specimen
12 hour urine
Addis Count
Preservative
Sodium Flouride
Normal Values
RBCs
WBCs & ECs
Hyaline Casts
0 - 500,000
0 - 1,800,00
0 - 5,000
Used for routine urinalysis
Bright-Field Microscopy
Identification of cholesterol molecules in OFB, fatty casts and crystals
Polarizing Microscopy
Identification of Treponema spp
Dark-Field Microscopy
For fluorescent microorganisms or those stained with a fluorescent dye
Fluorescence Microscopy
Delineates structure and contrasting colors of the nucleus and cytoplasm
SternheimerMalbin (CV + Safranin O)
Enhances nuclear detail
0.5% Toluidine Blue
Lyses RBCs and enhances nucleus of WBCs
2% Acetic acid
Differentiates Gram (-) to Gram (+) bacteria
GS
Stains eosinophilic granules
Hansel Stain
Lipid stains components
ORO and Sudan III
Distinguishes RBCs from WBCs, yeasts, oil droplets and crystals
2% Acetic acid
WBCs, ECs, and casts
SternheimerMalbin
Differentiates WBCs and RTE cells
0.5% Toluidine Blue
Identifies free fat droplets and lipidcontaining cells & casts
Lipid stains
Bacterial casts
GS
Identifies hemosiderin granules in casts and cells
Prussian Blue
Quantitated per LPF
Epithelial Cell
Mucus Thread
SEC
Per LPF
Quantitated Per HPF
RBCs
WBCs
Crystals (normal)
Bacteria
TEC, yeasts
OFB
Abnormal crystals and casts
Quantitated Per 10 HPF
RTE cells
None: 0
Rare: 0-5
Epithelial Cell
Rare: 0-2
Crystals (normal)
Rare: 0-10
Bacteria
Rare: 0-1
Mucus Thread
Few: 5-20
Epithelial Cell
Few: 2-5
Crystals (normal)
Few: 10-50
Bacteria
Few: 1-3
Mucus Thread
Moderate: 20-100
Epithelial Cell
Moderate: 5-20
Crystals (normal)
Moderate: 50-200
Bacteria
Moderate: 3-10
Mucus Thread
Many: >100
Epithelial Cell
Many: >20
Crystals (normal)
Many: >200
Bacteria
Many: >10
Mucus Thread
Numerical ranges: 0-2, 2-5, 5-10, >10
Casts
Numerical ranges: 0-2, 2-5, 5-10, 10-25, 25-50, 50-100, >100
RBCs
WBCs
Average
OFB
*quantitate an average of [?].
10 representative fields
Do not quantitate [?], but note their presence.
budding yeast, mycelia, elements, Trichomonas, or sperm
Urinary Sediment Constituents : A. CELLS
- Red blood cells (Hematuria)
- White blood cells (Pyuria)
- Epithelial Cells
- Bacteria
- Parasites
- Yeasts
- Spermatozoa
- Mucus thread
Urinary Sediment Constituents : CASTS
Hyaline cast
RBC cast
WBC cast
RTE cell cast
Bacterial cast
Granular casts
Fatty cast
Waxy cast
Broad cast
Pigmented cast
Mixed cellular cast
Crystal cast
Urinary Sediment Constituents : CRYSTALS - ACID
Amorphous urates
CaOx
Calcium sulfate
Hippuric acid
Acid urate
Sodium urate
Urinary Sediment Constituents : NORMAL CRYSTALS - Alkaline
Amorphous phosphate
Ammonium biurate
Calcium phosphate/apatite
Dicalcium phosphate
Triple phosphate
Calcium carbonate
Urinary Sediment Constituents : ABNORMAL CRYSTALS - Acid
Cystine
Cholesterol crystal
Sulfonamide
Ampicillin
Leucine
Tyrosine
Bilirubin
Urinary Sediment Constituents : ABNORMAL CRYSTALS - Acid/Neutral
Sulfonamide
Ampicillin
Leucine
Tyrosine
Smooth, non-nucleated, biconcave disks-shaped sediment (7um in diameter)
Red blood cells
Sources of error: Yeast, oil droplets, air bubbles, CaOx monohydrate
Red blood cells
Remedy: Addition of 2% HAc to lyse RBCs
Red blood cells
Clinical Significance: Glomerular membrane damage, vascular injury within GUT, glomerular bleeding, glomerulonephritis, renal calculi, malignancies, Schistosomiasis, strenuous exercise
Red blood cells
predominant
Neutrophils
Granulated and multilobed
Neutrophils
Swells in hypotonic (dilute and alkaline) urine and granules undergo Brownian Movement (Glitter Cells) *clinically insignificant
Neutrophils
Shrinks in hypertonic (acidic) urine
Neutrophils
Present in small amount
Mononuclear cells
An increase indicates an inflammatory response or renal transplant rejection
Mononuclear cells
Clinical Significance: infection or inflammation in the GUT
Mononuclear cells
Bacterial infection: cystitis, pyelonephritis, prostatitis, urethritis
Mononuclear cells
Non-bacterial infection: glomerulonephritis, SLE, tumors
Mononuclear cells
Largest cell (30-40 um) with abundant, irregular cytoplasm and prominent nucleus
Squamous epithelial cell
Folded cell may resemble casts. Found in the linings of vagina, female urethra and lower portion of male urethra
Squamous epithelial cell
o Spherical, polyhedral or caudate with centrally located nucleus
Transitional epithelial cell
o From linings of renal pelvis, calyces, ureter, urinary bladder and upper portion of male urethra.
Transitional epithelial cell
o Significant numbers can be seen after catheterization (single, pairs, or in clumps {syncytia})
Transitional epithelial cell
Oblong or round to oval or rectangular and contain an eccentric nucleus and coarsely granulated cytoplasm
Renal tubular epithelial (RTE) cell
o Lipid-containing RTE cell
o Seen in lipiduria (i.e. nephrotic syndrome)
Identification of RTE
Lipid Stains
Polarizing Microscope
o RTE cell with nonlipid-filled vacuoles
o Seen in acute tubular necrosis
may be mistaken for WBCs
RTEs from the distal convoluted tubules
Reporting of Epithelial Cells
RFMoMa
o Squamous (LPF)
o Transitional (HPF)
Reporting of Epithelial Cells
Ave. number per HPF
o RTE Cell
o Oval Fat Bodies
Parasites
Trichomonas vaginalis
Schistosoma haematobium ova
Enterobius vermicularis
Trichomonas vaginalis
Pear-shaped flagellate
Blood fluke with terminal spine
Schistosoma haematobium ova
Causes hematuria
Schistosoma haematobium ova
Small, refractile oval structures that may or may not bud
Yeasts
seen in DM patients and _____________
Candida albicans
formed in the DCT and collecting ducts
CASTS (Cylindruria)
Factors that favors cast formation
- Urine stasis
- High salt concentration
- Low pH
Formation of Casts
- Aggregation and concentration of THP into fibrils that attaches to RTE cells.
- Interweaving of protein fibrils into a mesh-like pattern.
- (Possible) attachment of urinary sediments to the matrix
- Detachment and excretion
Order of Cast Degeneration
Pathologic: glomerulonephritis, pyelonephritis, CHF
Hyaline cast
May be within the nephron confused with EC casts *use phase contrast or a supravital stain
WBC cast
Pyelonephritis
Acute interstitial nephritis
WBC cast
Advanced tubular destruction Renal tubular damage
RTE cell cast
Pyelonephritis
6Bacterial cast cast
Identification using Gram Staining
Bacterial cast cast
Not stained by SternheimerMalbin stain
Fatty cast
Identified using lipid stains and polarizing microscope
Fatty cast
Neph rotic syndrome (Lipiduria)
Fatty cast
Brittle, highly refractile with jagged edges
Waxy cast
Stasis of urine flow
Waxy cast
Indicates widening of the tubular walls
Broad cast
Extrem e urine stasis
Broad cast
Renal failure
Broad cast
Hyaline matrix with coloration due to pigmentation incorporation
Pigmented cast
Incorporated bilirubin
(golden brown)
Hemoglobin or myoglobin
(yellow to red brown)
Casts containing multiple cell types
Mixed cellular cast
Glomerulonephritis (RBC and WBCs)
Mixed cellular cast
Pyelonephritis (WBC, RTE casts or WBC and bacterial casts)
Mixed cellular cast
Casts containing urates, CaOx, and sulfonamides are occasionally seen
Crystal cast
Deposition of crystals in the tubule or collecting duct
Crystal cast
formed by precipitation of urinary solutes (organic compounds, salts, medication, etc.)
URINARY CRYSTALS
“2 pyramids joined at their bases”
Dihydrate
oval or Dilute HCl; Insoluble in HAc dumbbell Calcium sulfateshaped
Monohydrate
Yellowbrown/colorless elongated prisms
Hippuric acid
large granules and may have spicules
Acid urate
Slender prisms arranged in fan or sheaf like structures
Sodium urate
Granular; white ppt
Amorphous phosphate
Dilute HAc
Amorphous phosphate
Calcium phosphate/apatite
Triple phosphate
Gas from HAc
Calcium carbonate
insoluble by heat
Calcium phosphate/apatite
Heat with HAc
Ammonium biurate
Water and Ether
Hippuric acid
Acetic aci d
Calcium sulfate
Insoluble in HAc
CaOx
- basic calcium PO4
a. Hydroxyapatite
- calcium hydrogen PO4
b. Brushite
Long slender prisms with one end pointed; found in clusters
Dicalcium phosphate
Presence of ureasplitting bacteria
Ammonium biurate
Triple phosphate
Small, colorless, dumbbell-shaped.
Calcium carbonate
Formation of gas (effervescence) after the addition of acetic acid
Calcium carbonate
Colorless, hexagonal plates (Piattos)
Cystine
Dilute HCl and Ammonia
Cystine
colorless to yellow needles
Tyrosine
soluble in HAc, while sulfonamide is positive with Lignin and Diazo rxn
Sulfonamide
Solubility: Acetone
Sulfonamide
Solubility: Refrigeration = bundles
Ampicillin
- volume of sediment after decantation
- volume of sediment for microscopic examination
- produces a 3-D image by differential contrast
- two components of Hansel stain
- most significant epithelial cell
- reporting of #5
- quantity of #5 considered as significant
- condition indicated by #7
- RBCs in hypotonic are known as _____
- WBCs with sparkling appearance
- What type of WBC is #10?
- most frequently seen parasite in urine
- When does the presence of spermatozoa in urine reported?
- more common form of calcium oxalate
- color of amorphous urates in fresh urine
- compounds that precipitate in acidic urine forming crystals
- stain used for the identification of eosinophils
- stains used to confirm the presence of oval fat bodies
- parasite considered as most common fecal contaminant
- primary factor affecting in vitro crystallization
- metabolic disorder associated with uric acid crystals
- percentage of mononuclear cells implicated in chronic inflammation
- bubble cell is originally what specific cell
- primary factor affecting in vivo crystallization
- sediment that may accompany S. haematobium
POINTS to PONDER…..
A 2-year-old left unattended in the garage for 5 minutes is suspected of ingesting antifreeze. What type of crystal would you expect to be present? What urine pH correlates with this crystal?
of urinary sediment is the third part of routine urinalysis, after physical and chemical examination.
Microscopic examination
The purpose is to detect and to identify [?] present in the urine.
insoluble materials
Since some urinary sediments are of no clinical significance and others are considered normal unless they are present in increased amounts, examination of the urinary sediment must include both [?] of the elements present.
identification and quantitation
Take note of the following under the LPO:
Shift to HPO and take note of the presence of the following:
Microscopic Quantitation:
Epithelial cells/LPF
Crystals/HPF
Bacteria/HPF
RBCs/HPF
WBCs/HPF
Casts/LPF
Mucous threads
Do not quantitate [?], but do note their presence based on laboratory practice.
budding yeasts, mycelial elements, trichomonas or sperms
Heat and alkali flui
Amorphous urates
Dilute HCl; Insoluble in HAc
CaOx
Acetic acid
Calcium sulfate
Water and ether
Hippuric acid
Dilute HAc
Amorphous phosphate
Triple phosphate
Heat with HAc
Ammonium biurate
Dilute HAc; Insoluble by heat
Calcium phosphate/apatite
Gas from HAc
Calcium carbonate
Seen in old specimens
Ammonium biurate
Colorless, hexagonal plates (piattos)
Cystine
Cyanide-nitropruside test
Sulivan test
Cystine
Colorless to yellow-brown needles
Sulfonamide
Overdose of penicillin drugs
Ampicillin
Oily-looking spheres with concentric circles and radial striations
Leucine
