FORMED ELEMENTS: CELLS Flashcards by Kyra Catedral

Components of Urine Sediment

Organized Components (8)
Unorganized Components (3)

RBCs, WBCs, Epithelial Cells,
Casts, Bacteria, Yeast, Parasites, Spermatozoa

Crystals of Various Salts
1. Oxalate
2. Phosphates
3. Urates

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is the presence of abnormal numbers of RBCs in the urine due to:
• Glomerular Damage
• Kidney Trauma
• Renal Stones
• Cystitis & Pyelonephritis

Hematuria

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• Red blood cells may also contaminate from_____ or _______

menstruating women or

trauma from bladder catheterization

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If_______ red cells can be found in every high power field, and if contamination can be ruled out, the specimen is probably abnormal.

one or more

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• RBCs may appear normally shaped, swollen by____ urine, or crenated by____ urine.

dilute

concentrated

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Swollen, partly hemolyzed, and crenated RBCs are difficult to distinguish from WBC granules in the urine.

•________ may indicate glomerular bleeding.

Dysmorphic RBCs

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• Under HPO, unstained RBCS
appear as pale biconcave disks.

• If the specimen is not fresh, they may appear as faint, colorless circles known as “______”

ghost cells

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RBCs become faint, colorless because the hemoglobin may dissolve out in old specimen.

Shadow Cells

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Found in hypotonic/diluted urine, the cells will rapidly lyse releasing the hemoglobin and leaving only the empty cell membranes.

Ghost Cells

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• A doughnut - shape RBCs with one or more membrane blebs, may be more specific that dysmorphic cells for diagnosing glomerular hematuria.

G1 Cells
Acanthocytes

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• Pus cells or WBC in urine are mostly…

polymorphonuclear leukocytes (neutrophil)

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WBC

• In STERNHEIMER MALBIN, nuclei appear _____and cytoplasmic granules____.

reddish purple

violet

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• In dilute or hypotonic urine, neutrophils swell and their cytoplasmic granules exhibit Brownian movement. -_____

Glitter Cells

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Largest - point of focus

SECs

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• Irregularly angled cells with distinct edges, that may be present in clumps.
• Originates from the linings of the vagina and female urethra and the lower portion of the male urethra
• Centrally located nucleus about a size of RBC Or WBC

SECs

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Flagstone shaped

SECs

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Squamous EC

Cytoplasm contains “______ granules”

keratohyalin granules

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Indicates the age of Epithelial Cells

Keratohyalin granules

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• A SEC covered with a coccobacillus attached in clusters on the cell
surface.

Clue Cells

Indicative of Trichomonas vaginalis

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Clue cells

• The bacteria should cover at least____% of the epithelial cell.

75%

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• Diagnostic for bacterial vaginosis

Clue cells

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Normal flora (bacteria)

Lactobacillus

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is a Gram stain-based scoring system used to diagnose bacterial vaginosis (BV) by assessing the presence and abundance of different bacterial morphotypes in vaginal swabs.

The Nugent score

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The Nugent score

It assigns scores based on the relative abundance of (3)

Lactobacillus
Gardnerella/Bacteroides, and Mobiluncus bacteria

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Nugent’s score A score of____ indicates normal vaginal flora,____ suggests an intermediate state, and____ is indicative of bacterial vaginosis.

0-3 4-6 7-10

• Smaller that SEC; spherical, polyhedral, caudate - tail • Originate from the ***renal pelvis, ureter, calyces, or bladder*** • Single, Pairs, Groups

Transitional EC

Transitional (Urothelial) ECs The cells in the upper- most or ***superficial layer*** are large (30–40 μm) and usually _______shaped. Cells from the ***intermediate layers or from the trigone region*** of the bladder are_______ (i.e., with a cytoplasmic tail), or club-like, and their nucleus is usually off- center. Those from the ***deep basal layer*** are smaller (15–30 μm) and tend to be______

round or pear-shaped elongated, caudate rectangular

are transitional or renal tubular epithelial cells that are infected with ***polyomavirus***of the BK virus (BKV) strain.

Decoy cells

Most clinically significant type of epithelial cells

RTECs

• Notice the size comparison with the WBC • Prominent and distinct nucleus--eccentric

RTECS

• When lipiduria occurs, these cells contain endogenous fats - OVAL FAT BODIES Indicates cell death or glomerular dusfunction

RTECs

Mucus threads are produced by…

RTECs

• Protein material produced by the glands and epithelial cells of the lower genitourinary tract and the RTE cells.

Mucus threads

Mucus threads is its major constituent Thread- like structures with low refractive index.

• Tamm Horsfall protein

How to differentiate mucus threads from hyaline casts? Stain with?

Sternheimer Malbin Hyaline casts are pink

CASTS Unique to the kidneys, formed in the (2)

DCT and collecting ducts.

CASTS • Composed of a core matrix of..

uromodulin Tamm Horsfall

• Cylindrical in shape and appearance • Uromodulin excretion: stress and exercise

CASTS

Casts formation process 1.______ of Tamm Horsfall protein into individual protein fibrils attached to RTE cells 2.____ of protein fibrils to form a loose fibrillary network (urinary constituents may become enmeshed in the network at this time) 3. Further protein fibril interweaving to form___ 4. Possible attachment of____ to the solid matrix 5. Detachment of protein fibrils from the____ 6.____ of the cast

Aggregation Interweaving solid structure urinary constituents epithelial cells Excretion

Order of casts degeneration

Hyaline Cellular Degeneration of cells Coarse granular Fine granular Waxy

Factors favoring protein cast formation (3)

1. Low flow rate 2. High salt concentration 3. Low pH

• ***Protein casts with long, thin tails*** formed at the junction of Henle's loop and the distal convoluted tubule are called_____. • Hyaline casts can be seen even in healthy patients

cylindroids

Immature or incomplete casts

Cylindroids

which appear ***colorless and slightly refractile,*** are common findings in urine •___-____/pf is normal

• Hyaline casts 0-2

• Seen after strenuous exercise, dehydration, heat exposure, and emotional breakdowns in life hehehe

Hyaline casts

• Greater numbers of _____may be seen associated with proteinunia of renal glomerular disease or extrarenal (overflow proteinuria as in myeloma) • Stain with Sternheimer Malbin: Pink

hyaline casts

• The presence of this_____ on urine microscopic analysis suggests a glomerular bleeding, renal tubular injury, or ***bleeding in any part of the nephron***

red blood cell cast

RBC casts Degenerated to a reddish-brown granular cast called a_______ cast

hemoglobin/blood/muddy brown cast

Stain for RBC cast • RBC Cast:______ color at LPO

Trichrome stain Orange-red

RBC Casts •______ color: Massive hemoglobinuria or myoglobin •______: hemoglobin degradation products

Red-brown Granular, dirty brown

More fragile than the other casts

RBC cast

Most typical for acute pyelonephriits Used to differentiate upper from lower UTI May also be present in AIN

WBC casts

Their presence indicates inflammation of the kidney, because such casts will not form except in the kidney • Granular • If disintegrated, multilobed nuciei will be present (stained supravitally)

WBC casts

• Renal Tubular Cells seen are small, round, and oval Slightly larger than leukocytes (10-14um) with granular cytoplasm • Use stains and phase microscopy to differentiate from WBC

RTE Cast

• Represents advanced tubular destruction; Bilirubin-stained RTE cells seen in______ • May accompany WBC Casts in Pyelonephritis

Hepatitis

• They are identified by the presence of refractile lipid droplets • The background matrix of the cast may be hyaline or granular

-Fatty cast

• Seen in conjunction with OFB • Nephrotic Syndrome tubular toxic necrosis, DM, and crush injuries

Fatty Cast

To confirm presence of cholesterol, use…

Polarizing microscope

• Most commonly RBC and WBC casts in glomerulonephritis • Predominant cast should be RBC casts • Pyelonephritis • WBC and RTE Casts • WBC and Bacterial Casts • Predominant cast should be WBC casts

Mixed cellular cast

Cast containing multiple cell types Any combination is possible

Mixed cellular casts

• Pathologic or Non - pathologic • When cellular casts remain in the nephron for some time before they are flushed into the bladder urine, the cells may degenerate to become a…

coarsely granular cast

• Clumps of small crystals and fecal debris may look like … • Distinguish from columnar RTE cells by staining to enhance nuclear detail

coarsely granular cast

• They have a smooth consistency but are more refractile and easier to see compared to hyaline casts • Represents extreme urine stasis

Waxy casts

• They commonly have squared off, jagged and notched ends, as if brittle and easily broken • They are found especially in chronic renal diseases • Glomerulonephritis

Waxy cast

Waxy cast • Sternheimer - Malbin -

homogenous dark pink

RENAL FAILURE CAST

Waxy cast

• Represents extreme urinary stasis • Indicates widening of DCT

Broad cast

May indicate- tubular necrosis by viral hepatitis

Bile-stained waxy casts

When suspended in urine sediment, they can be viewed from any angle. When viewed from the side, they have an ***hourglass shape;*** when viewed from above, they ap- pear as disks with a central pallor

RBCs

The size or diameter of RBCs is affected by urine concentration (i.e., osmolality, specific gravity). In hypertonic urine, their diameter can be as small as _____and in hypotonic urine as large as_____

~ 3 μm 11.8 μm.

The most common dysmorphic form of RBCs is_________. When RBCs are present in hypertonic urine (osmolality _____mOsm/L), they become smaller as intracellular water is lost by osmosis, which causes them to become crenated. As they crenate, erythrocytes lose their biconcave disk shape and become ***spheres covered with evenly spaced spicules or crenations.*** Because of these reversible membrane changes, the surface of crenated cells appears rough or sometimes grainy, depending on the microscope adjustments, compared with normal erythrocytes.

crenated erythrocytes (i.e., echinocytes or burr cells) >500 mOsm/L

In hypotonic urine (osmolality ______mOsm/L), erythrocytes swell and will eventually release their hemoglobin to become_____, which are ***cells with intact cell membranes but no hemoglobin.***

<180 mOsm/L “ghost” cells

These empty cells, outlined by their membranes, appear as colorless empty circles. Because their hemoglobin has been lost, these cells are difficult to see using brightfield microscopy; however, they are readily visible with______ or ______ microscopy

Ghost cells phase contrast or interference contrast

Note that____ urine promotes RBC lysis and disintegration, which results in ghost cells and erythrocyte remnants.

alkaline

The presence of_______ in urine is particularly noteworthy. The conversion of RBCs into _____ is not induced by changes in osmolality or pH. Rather, the physical forces undergone by RBCs as they pass through the glomerular filtration barrier (i.e., base- ment membrane) disrupt and permanently alter their cell membranes.

acanthocytes (i.e., RBCs in a donut form with one or more protruding cytoplasmic blebs)

Studies indicate that when ***5% or more of the RBCs in urine sediment*** are______, it is an indicator of ***hematuria due to a glomerular disorder.*** Rarely observed are____, which have been seen in the urine sediment of patients with sickle cell disease. Using ***phase contrast or interference contrast microscopy*** enhances the ability to evaluate RBC morphology and is recommended.

Acanthocytes sickle cells

Normally, RBCs are found in the urine of healthy individuals and do not exceed______per high-power field or_____per microliter of urine sediment

0 to 3 per HPF 3 to 12 per mL