AUBF Lesson 1 Flashcards by Todd Chavez

should be examined while fresh or adequately preserved

specimen preparation

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Specimen volume

10-15 ml

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5 minutes at a relative centrifugal force of 1,200

Centrifugation

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decant (0.5-1 ml)

Sediment preparation

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20 uL

Volume of sediment examined

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10 fields both in low and high power

Examination of sediment

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Identifies WBCs, epithelial cells & casts

Sternheimer-Malbin

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Delineate structure and contrasting colors of the nucleus & cytoplasm

Sternheimer-Malbin

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Differentiates WBCs from Renal tubular epithelial cells

Toluidine Blue

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Enhances nuclear
detail

Toluidine Blue

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Distinguish RBCs
from WBCs, yeast,
oil droplets

2% Acetic Acid

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Lyses RBCs and
enhances nuclei of
WBCs

2% Acetic Acid

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Identify bacterial
casts

Gram stain

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Differentiates
gram (+) from gram
(-) bacteria

Gram stain

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Identify urinary
eosinophils

Hansel Stain

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Stain eosinophilic
granules

Hansel Stain

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URINARY SEDIMENTS ARE CLASSIFIED INTO:

Organized sediments
Unorganized sediments

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Include epithelial cells, leukocytes, erythrocytes,
casts, parasites, bacteria, semen

Organized sediments

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Fat droplets, mucus thread, crystals, artefacts

Unorganized sediments

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swells (ghost cells)

Hypotonic solutions

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shrink (crenated cells)

Hypertonic Solutions

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Reported as to number of cells seen per HPF

RBCs = Red Blood Cells

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larger than RBCs size of 12 μm

WBC

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Predominant WBC in urine
When exposed to hypotonic solution, it swells
Brownian movement of granules, produces a
sparkling appearance referred to as glitter cells

Neutrophils

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- Associated with drug induced interstitial nephritis - Preferred stain is Hansel’s stain - Wright stain can be used

Eosinophils

- Lymphocytes, monocytes, macrophages & histiocytes

Mononuclear cells

fewer than 5/HPF found in normal urine

WBC

increase in urinary WBC, indicates presence of infection

pyuria

represent normal sloughing of old cells

EPITHELIAL CELLS

an epithelial cell in urine test looks at urine under a microscope to see if the number of your epithelial cells is in the normal range. It’s normal to have a small amount of epithelial cells in your urine. A large amount may indicate an infection, kidney disease, or other serious medical condition

EPITHELIAL CELLS

to be reported as rare, few, moderate, many

EPITHELIAL CELLS

largest cells found in urine sediment

Squamous

TYPES OF EPITHELIAL CELLS

Squamous Transitional Epithelial (urothelial cells) Renal Tubular Epithelial Cells

contain abundant, irregular cytoplasm and a prominent nucleus about the size of a RBC

Squamous

Reported in terms of rare, few, moderate and many

Squamous

Originate from the linings of vagina & female urethra & lower portion of male urethra

Squamous

Midstream clean catch technique will contain less contamination

Squamous

Variation of squamous EC is CLUE CELLS (Gardnerella vaginalis)

Squamous

Smaller than squamous cells & appear in several forms (spherical, polyhedral, caudate)

Transitional Epithelial (urothelial cells)

Has the ability to absorb large amount of water

Transitional Epithelial (urothelial cells)

Originate from the lining of renal pelvis, ureters, bladders & upper portion of male urethra

Transitional Epithelial (urothelial cells)

Transitional cells with abnormal morphology maybe indicative of malignancy of viral infection

Transitional Epithelial (urothelial cells)

Vary depending on the area of the renal tubules from which they originate

Renal Tubular Epithelial Cells

Cells from PCT have coarsely granulated cytoplasm

Renal Tubular Epithelial Cells

Cells from collecting ducts are finely granulated

Renal Tubular Epithelial Cells

Absorb lipids present in glomerular filfrate

Renal Tubular Epithelial Cells

- Vary depending on the area of the renal tubules from which they originate - Cells from PCT have coarsely granulated cytoplasm - Cells from collecting ducts are finely granulated - Absorb lipids present in glomerular filfrate

Renal Tubular Epithelial Cells

- Smaller than squamous cells & appear in several forms (spherical, polyhedral, caudate) - Has the ability to absorb large amount of water - Originate from the lining of renal pelvis, ureters, bladders & upper portion of male urethra - Transitional cells with abnormal morphology maybe indicative of malignancy of viral infection

Transitional Epithelial (urothelial cells)

- largest cells found in urine sediment - contain abundant, irregular cytoplasm and a prominent nucleus about the size of a RBC - Reported in terms of rare, few, moderate and many - Originate from the linings of vagina & female urethra & lower portion of male urethra - Midstream clean catch technique will contain less contamination - Variation of squamous EC is CLUE CELLS (Gardnerella vaginalis)

Squamous

 represent normal sloughing of old cells  an epithelial cell in urine test looks at urine under a microscope to see if the number of your epithelial cells is in the normal range. It’s normal to have a small amount of epithelial cells in your urine. A large amount may indicate an infection, kidney disease, or other serious medical condition  to be reported as rare, few, moderate, many

EPITHELIAL CELLS

 Not normally present in urine  May produce positive nitrite, pH above 8.0  In the form of cocci or baccili  LPO  Reported as few, moderate, many

BACTERIA

 Protein material produced by glands & epithelial cells  Appear as thread-like structure  No clinical significance  Reported as few, moderate, many  Tamm-horsfall protein is its major constituent

MUCUS

 Appear as small, refractile oval structures with buds or mycelia  Reported as few, moderate, many  Primarily Candida albicans  Maybe seen in urine of diabetic, immunocompromised patients

YEAST

 T. vaginalis (a pear-shaped flagellate)  Sexually transmitted  E. vermicularis, S. hematobium

PARASITES

 Urine is toxic to sperm – tapered oval head with long, thin tail

SPERMATOZOA

 Formed within the lumens of the distal convulated tubules & collecting ducts  Their shape is representative of the tubular lumen  Parallel sides & somewhat rounded ends & may contain additional elements present in the filtrate  Reported as the average number per 10 LPF  Major constituent is Tamm-Horsfall protein Glycoprotein excreted by RTE cells of the distal convoluted tubules & upper collecting ducts  Cylindruria (presence of urinary casts)

CASTS

TYPES OF CASTS

HYALINE TEST RED BLOOD CELLS CASTS WHITE BLOOD CELLS CASTS BACTERIAL CASTS EPITHELIAL CELL CASTS MIXED CELLLULAR CASTS GRANULAR CASTS WAXY CASTS

- Frequently seen casts - Consists almost entirely of Tamm Horsfall protein - Preserve of 0-2/LPF is considered normal - Strenouos exercise, dehydration, heat exposure &emotional stress - Pathologically, in acute glomerulonephritis, chronic renal disease, pyelonephritis, congestive heart failure - Appears colorless - Sternheimer-Malbin stain produces pink color

HYALINE TEST

- Shows bleeding within the nephron - Associated with glomerulonephritis - Can be easily detected by their orange-red color - More fragile than other casts

RED BLOOD CELLS CASTS

- Signifies infection & inflammation within the nephron - Associated with pyelonephritis - Present in non-bacterial inflammation such as interstitial nephritis - Primary marker to distinguish upper UTI (pyelonephritis) - From lower UTI - Composed of neutrophils, appear granular, multilobed nuclei

WHITE BLOOD CELLS CASTS

- Containing bacilli - Seen in phylonephritis - Difficult to identify - Confirmation bacterial cast – perform gram stain on centrifuge sediment

BACTERIAL CASTS

- Indicates advanced tubular destruction - Associated with drug induced toxicity, viral infections, & allograft rejections - Cells visible are smaller, cuboidal & columnar shaped cells

EPITHELIAL CELL CASTS

- Frequently encountered are RBC & WBC casts in glomerulonephritis - WBC & bacterial casts in pyelonephritis - When mixed casts are present, there should be a homogenous cast of at least one cell type - Example: > WBC cast in pyelonephritis > RBC cast in glomerulonephritis

MIXED CELLLULAR CASTS

- Coarsely & finely granular cast - Seen after strenuous exercises in disease state, granules may represent disintegration of cellular casts & protein aggregates filtered by the glomerulus - Easily visualized under LPO, final ID at HPO

GRANULAR CASTS

- Granular casts remain in the tubules for an extended period - Granules disintegrate, cast matrix develops a waxy appearance - Structures becomes more rigid; end of the casts may appear jagged or broken - Diameter becomes broader

WAXY CASTS

- Of rare clinical significance - To detect the presence of relatively few abnormal types - May represent disorders such as liver disease, inborn errors of metabolism - Reported as few, moderate, many - Precipitation of urine solutes - Crystal formation takes place at low temperature - Presence of crystals in freshly voided urine is associated with concentrated high specific gravity specimen - pH: valuable aid in ID of crystals - organic compounds crystallize more easily in acid pH - inorganic in neutral or alkaline

URINARY CRYSTALS

o Yellow brown granules o Refrigerated specimen, produce pink sediment (accumulation of uroerythrin)

Amorphous urates

o Variety of shapes o Rhombic, four-sided flat plates, wedges & rosettes o Yellow brown, colorless o Highly birefringent under polarized light o Associated with increased levels or purines & nucleic acid o Seen in patients with leukemia undergoing chemotheraphy

Uric acid crystals

o Needle shape o Seen in synovial fluid in episodes of gout

Sodium urate

o Octahedral envelop o Birefringent under polarized light o Associated with food in high oxalic acid such as tomatoes, asparagus & ascorbic acid o Primary pathologic significance in cases of ethylene glycol poisoning

Calcium oxalate

NORMAL CRYSTALS IN ACIDIC URINE

Amorphous urates Uric acid crystals Sodium urate Calcium oxalate

NORMAL CRYSTALS SEEN IN ALKALINE URINE

Phosphate Amorphous phosphate Triple phosphate Calcium phosphate crystals Calcium carbonate crystals Ammonium biurate

Majority of the crystals found in alkaline urine

Phosphate

o Granular in appearance o Does not dissolve in warming

Amorphous phosphate

o Colorless, prism shape that resembles a coffin lid o As they disintegrate, crystals may develop a feathery appearance o Birefringent under polarized microscope associated with urea-splitting bacteria

Triple phosphate

o Colorless, flat rectangular plates, thin prisms in rosette formation o Dissolve in dilute acetic acid

Calcium phosphate crystals

o Small, colorless, dumbbell or spherical shape o May occur in clumps o Distinguish by the formation of gas after the addition of acetic acid o Have no clinical significance

Calcium carbonate crystals

o Thorny apple o Spicule covered spheres o Dissolve at 60C o Upon addition of glacial acetic acid, It will be converted to uric acid crystals

Ammonium biurate

found in acidic urine

ABNORMAL URINARY CRYSTALS

o Found in patients with metabolic disorder that prevent reabsorption of cystine by renal tubules o colorless, hexagonal plates o difficult to differentiate from uric acid crystals o (+) confirmation with cyanide nitroprusside tests

Cystine crystals

o Rarely seen unless specimenhave been refrigerated o Rectangular plate with a notch in one or more corners o Birefringement with polarized light o Associated with disorders producing lipiduria, such as nephrotic syndrome

Cholesterol crystals

ABNORMAL URINARY CRYSTALS

Cystine crystals Cholesterol crystals

CRYSTAL ASSOCIATED WITH LIVER DISORDERS

TYROSINE LEUCINE BILIRUBIN SULFONAMIDE CRYSTALS AMPICILLIN CRYSTALS

o Appear as fine colorless to yellow needles that frequently form clumps or rosettes o Seen with leucine crystals in specimen with positive chemical tests for bilirubin o Seen in patients with disorders of amino acid metabolism

TYROSINE

o Yellow brown spheres o Demonstrate concentric circle & radial striations o It is with tyrosine crystals

LEUCINE

o Present in hepatic disorders o Appear as clumped needles or granules o Yellow in color o A positive chemical test with bilirubin

BILIRUBIN

o Inadequate patient hydration o With variety of shapes & colors which include needles, rhombics, sheaves, rosettes, colors ranging from colorless to yellow brown o Diazo reaction for confirmation

SULFONAMIDE CRYSTALS

o Appear colorless needles that tend to form bundles following refrigeration

AMPICILLIN CRYSTALS

URINARY SEDIMENT ARTIFACTS

 Starch granules  Oil droplets  Air bubbles  Hair  Diaper fibers