MICROSCOPIC EXAMINATION Flashcards
The least standardized and most time- consuming part of the routine urinalysis
MICROSCOPIC EXAMINATION OF URINE
WBCs, WBC casts, Bacteria
Leukocyte Esterase
Casts, Cells
Protein
Bacteria, WBCs
Nitrite
Yeast (presence of glucose) + WBC = Fungal infection
Glucose
Specimen volume must be?
Adult?
If pedriatic?
10-15 mL
12 mL
In sediment preparation, Volumes of ____ and _____ mL are frequently used for microscopic exam.
0.5 and 1.0 mL
When using the conventional glass-slide method, the recommended volume is _____ covered by a ______ mm glass cover slip.
20uL ( 0.02 mL) covered by 22x22 mm
are reported as the average number per lowpower field (lpf) following examination of 10 fields
Casts
as the average number per 10 highpower fields (hpf)
Rbcs and Wbcs
are frequently reported in semi-quantitative terms:
- rare, few, moderate, many
- 1+, 2+, 3+, 4+
Epithelial cells, crystals and other elements
Delineates structure and contrasting colors of the nucleus and cytoplasm.
Identifies WBCs, epithelial cells, and casts. Stains Neutrophil
SternheimerMalbin (Crystal Violet & Safranin
Enhances nuclear detail
Differentiates WBCs and renal tubular epithelial cells
Toluidine Blue
Lyses RBCs and enhances nuclei of WBCs
Distinguishes RBCs from WBCs, yeast, oil droplets, and crystals
2% Acetic Acid
Stains triglycerides and neutral fats orange-red
Lipid Stains (Oil Red O, Sudan III)
Differentiates gram-positive and gramnegative bacteria
Identifies bacterial casts
Gram stain
Methylene blue and eosin Y stain eosinophilic granules
Identifies urinary eosinophils
Hansel Stain (Methylene blue & Eosin Y)
Stains structures containing iron
Identifies yellowbrown granules of hemosiderin in cells and casts
Prussian Blue Stain
releasing their hemoglobin and leaving only the cell membrane
GHOST CELLS
urine, cells shrink due to loss of water and appear crenated or irregularly shaped
Concentrated/ hypersthenuric
Urine cells absorb water swell and lyse rapidly, releasing their
In dilute (hyposthenuric)
RBCs are the most difficult for students to recognize:
-RBCs’ lack of characteristic structures
- Variations in size
- Close resemblance to other sediment constituents
dissolves RBC, not the Yeast cells
Add acetic acid
RBC is red, Yeast is colorless
Stain with eosin
RBC with RBC cast (unique to the kidney) –
Renal disease
RBC without cast and protein
Damaged distal to the kidney
Intact RBC found in?
Lower Tract
Crenated RBC
Upper tract
Dysmorphic RBC found in:
- Abnormal urine concentration
- Glomerular bleeding
- Non glomerular hematuria (in small amount)
- Strenuous exercise (in small amount
cloudy with a red to brown color. Microscopic analysis may be reported in terms of greater than 100/hpf. TNTC (too numerous to count)
Hematuria
Larger than RBCs, measuring an average of about 12 um in diameter
White blood cells
The predominant WBC in urine
• Exhibit Brownian movement (false motility) – because of the presence of granules with sparkling appearance
Neutrophils
Stain for for glitter cell
Sternheimer malbin
Associated with drug-induced interstitial nephritis
• Small amount urinary tract infection (UTI) and renal transplant rejection
Eosinophils
True or false more than 1% eosinophils is considered significant
True
Stain use for eosinophil
Hansel stain
Lymphocytes, Monocytes, Macrophage, Histiocytes
• Found in small amount
Mononuclear cells
mistaken as RBC because of its small size
Lymphocytes (agranulocyte)
Increased amount in early renal transplant rejection
Mononuclear cells
increased urinary WBC
Pyuria
↑ WBC infection + cast • Cystitis + protein + bacteria • + turbidity + nitrite(gram negative) • - nitrite (gram positive)
Pyelonephritis
Cystitis
Prostatitis
Urethritis
↑WBC infection + cast + protein +turbidity - nitrite
Glomerulonephritis
Tumor
Interstitial nephritis
Lupus Erythematosus
Derived from the linings of the genitourinary system
Epithelial cells
Three types of epithelial cells are seen in urine:
Squamous
Rte cells
Transitional cells
•Largest cells found in the urine sediment
•Contain abundant, irregular cytoplasm and a
prominent nucleus about the size of an RBC
Squamous epithelial cells
Originate from the linings of the vagina and female urethra and the lower portion of the male urethra
Squamous epithelial cells
A variation of the squamous epithelial cell is called as?
Clue cells
indicative of vaginal infection by gardenella vaginalis
Clue cells
Smaller than squamous and appear in several forms:
- Spherical
- Polyhedral
- Caudate/ Cuboidal
Transitional epithelial cells
Originate from the lining of the renal pelvis (UT), calyces, ureters, bladder, and upper portion of male urethra
Transitional cells
•Most significant epithelial cell.
Vary in size and shape depending on the area of the renal tubules from which they originate – cuboidal, columnar with eccentrically located nucleus
RTE CELLS
More than 2 RTE cells/hpf caused what injury
Tubular injury
Lipid containing RTE CELLS
Seen in lipiduria
Oval fat bodies
Stain use to oval fat bodies
Sudan III / oil red o
- larger than other RTE cells
- Rectangular shape
- referred as columnar or convoluted cells
RTE IN PCT
smaller than those from the PCT
- round or oval/ spherical
RTE IN DCT
• Only elements found in urinary sediment that are unique to the kidney
• Formed within the lumens of the DCT and collecting ducts, providing a microscopic view of conditions within the nephron
• Condition associated with upper urinary tract
Casts
main component of casts matrix
Uromodulin
Matrix (boundary/ cell membrane) –
Tamm Horsfall Protein
(glycoprotein secreted by RTE cells in DCT and collecting ducts
Tamm Horsfall Protein
final degenerative form of all types of casts)
Waxy cast
presence of cast in urine
Cylinduria
Most frequently seen cast
• Least clinical significance
• Consists almost entirely of Tamm-Horsfall protein
• Presence of 0-2 hyaline casts /lpf is considered normal
Hyaline casts
strenuous exercise, dehydration, heat exposure, and emotional stress
Non-pathological causes of increase
acute glomerulonephritis, pyelonephritis, chronic renal disease, and congestive heart failure.
Pathological causes of increase
Rbc casts is Easily detected under LPO by their ______ color
Orange red
Indicates bleeding from an area within the GUT
• If the RBC observed microscopically is crenated, morphic which have damage in cell membrane that is associated with upper bleeding
Rbc casts
RBC casts associated with glomerular damage are usually associated with
increase proteinuria and dysmorphic erythrocytes
Primarily associated with damage to the glomerulus (glomerulonephritis) that allows passage of the cells through the glomerular membrane
Rbc casts
Signifies infection/inflammation within the nephron
•Infection depends on other structures that can be observe
Wbc casts
Most frequently associated with ________and an ________marker for distinguishing
pyelonephritis and upper uti from lower uti
(+) bacteria
(+) wbc cells
(+) wbc cast
Upper uti
(+) bacteria
(+) wbc
(-) wbc casts
Lower uti
with matrix as compared to WBC in clumps
Wbc casts
is bacterial infection,
Pyelonephritis
is nonbacterial infection
glomerulonephritis
Contain bacilli both within and bound to the protein matrix – seen in pyelonephritis
Bacterial casts
Confirmation of bacterial casts is best made by performing a?
cytocentrifuged sediment or Gram stain
Represent the presence of advanced tubular destruction, producing urinary stasis along with disruption of the tubular linings
Epithelial casts
epithelial cells that can be observed in urinary sediment:
Squamous
Rte
Transitional
never seen in epithelial cells casts; nonpathological; lower urinary tract)
Epithelial cell
stained RTE cells (Spherical) are seen in cases of hepatitis
Bilirubin
Fats do not stain with
Sternheimer-Malbin stains
Combination of Cellular Cast components in one matrix
MIXED CELLULAR CASTS
Most frequently encountered include:
- RBC and WBC casts in glomerulonephritis
- WBC and RTE cell casts, or WBC and bacterial casts in pyelonephritis
Mixed cellular casts
• Coarsely and finely granular casts are frequently seen in the urinary sediment
• May be of pathologic or non-pathologic significance
Granular casts
Representative of extreme urine stasis, indicating chronic renal failure
Usually seen in conjunction with other types of casts associated with the condition that caused the renal failure (granular casts
brittle, highly refractive cast matrix f
Waxy casts
They often appear fragmented with jagged ends and have notches in their sides
Waxy casts
Represent extreme urine stasis
•
Indicates destruction (widening) of the tubular walls.
Broad / renal failure casts
Most commonly – granular and waxy casts
• Associated with renal failure
Broad casts
Not normally present in urine (because the bladder is sterile where the urine stored)
Bacteria
To be considered significant for UTI, bacteria should be accompanied by
Wbc
UTI caused by
SES
Enterobacteriaceae, Staphylococcus and Enterococcus
• Small, refractile oval structures that may or may not contain a bud
• They may appear as branched, mycelial forms
Yeast
A true yeast infection should be accompanied by the presence of ____
and correlate to what analyte
WBC
Glucose
Yeast cells, primarily _______ (fungi), seen in diabetic, immunocompromised patients and women with
Candida albicans with vaginal moniliasis
The most frequent parasite encountered in the urine is ____________ easily identified in wet preparations of the urine sediment by its rapid darting movement in the microscopic field
Trichomonas vaginalis,
When not moving, Trichomonas is more difficult to identify and may resemble a
WBC,rte cells and transitional cells
Bacteria, parasite, fungi same manner of reporting which is
Semi quantitative
Oval, slightly tapered heads and long, flagella - like tails
Spermatozoa
instead going out to the urethra, it will going up to urinary bladder (sperm cell) and combine with urine which having a traces of sperm cell in sediment.
Retrograde ejaculation
Protein material produced by the glands and epithelial cells of the lower GUT and the RTE cells
Mucus
is a major constituent of mucus
Tamm-Horsfall protein
• Appears microscopically as thread-like structures with a low refractive index
Mucus
• Appears microscopically as thread-like structures with a low refractive index
Rte cells
Appear as true geometrically formed structures or as amorphous material
Urinary crystals
Formed by the precipitation of urine solutes, including inorganic salts, organic compounds, and medications
Crystal formation
appear yellow to reddish brown and are the only normal crystals found in acidic urine that appear colored
Urates crystals
not found in urine (Synovial fluid)
Sodium urates
Example of urates crystals
- Amorphous urates
- Uric acid
- Acid urates
- Sodium urates
• Appear as yellow- brown granules
• May occur in clumps resembling granular casts
• Common in refrigerated specimen
AMORPHOUS URATES
on the surface of the granules is the cause of the pink color
Uroerythrin
Seen in a variety of shapes – rhombic, four-sided flat plates (whetstones), wedges, and rosettes
• Usually appear yellow-brown, but may be colorless and have a six-sided shape, similar to cystine crystals
• Highly birefringent under polarized light, which aids in distinguishing from cystine crystals
Uric acid crystals
Increased amounts of uric acid crystals are associated with increased levels of purines and nucleic acids seen in patients with
Leukemia undergo to chemotherapy, and , Lesch-Nyhan syndrome and gout
appear as larger granules and may have spicules similar to the ammonium biurate crystals seen in alkaline urine
Acid urates
crystals are needle-shaped and are seen in synovial fluid during episodes of gout, but do appear in the urine
Sodium urates
• Rarely encountered
• Frequently seen in conjunction with amorphous urates
• have little clinical significance
Acid urates and sodium urates
Frequently seen in acidic urine, but can be found in neutral urine and rarely in alkaline urine
Calcium oxalate
Most common form of calcium oxalate
Dihydrate
Most common easily recognized as colorless, octahedral envelope or two pyramids joined at their bases
Dihydrate
Less common in calcium oxalate
Monohydrate
which are oval or dumbbell shaped
Monohydrate
Clumps of calcium oxalate crystals may be related to
Renal calculi
Common constituents of kidney stone
Calcium oxalate
__________ is form in cases of ethylene glycol poisoning
Monohydrate
• Common
• pH acid or neutral
• Envelope or dumb bell shaped
• Oval – may be mistaken for RBC
• Soluble in HCl; Insoluble in acetic acid
Calcium oxalate
represent the majority of crystals seen in alkaline urine
Phosphates crystals
Types of phosphates crystals
- Amorphous phosphates
- Triple phosphates
- Calcium phosphates
What are the NORMAL CRYSTALS SEEN IN ALKALINE URINE
• Calcium carbonate
• Ammonium biurate • Phosphates crystals
• Granular in appearance, similar to amorphous urates
• When present in large quantities following specimen refrigeration, they cause a white precipitate that does not dissolve on warming
AMORPHOUS PHOSPHATES
• Ammonium Magnesium phosphate crystals
• Commonly seen in alkaline urine
TRIPLE PHOSPHATE
Easily identified by their prism shape that frequently resembles a “coffin lid”
TRIPLE PHOSPHATE
Dissolve in dilute acetic acid and sulfonamides do not Resembles sulfonamide crystals (needle shape
CALCIUM PHOSPHATE
• “Sheets of Ice”
• Rosettes
• Associated with Cystitis and Urine retention
CALCIUM PHOSPHATE
Small and colorless, with dumbbell or spherical shapes
CALCIUM CARBONATE
• May occur in clumps that resemble amorphous material, but they can be distinguished by the formation of gas after the addition of acetic acid
• They are also birefringent, which differentiates them from bacteria
• No clinical significance
CALCIUM CARBONATE
Acidic normal crystals are?
- URATES CRYSTALS
- Amorphous urates
- Uric acid
- Acid urates
- CALCIUM OXALATE
Alkaline normal crystals are?
- Phosphates crystals
- Amorphous phosphates
- Triple phosphates
- Calcium phosphates
- Calcium carbonate
- Ammonium biurat
ABNORMAL CRYSTALS are
Cystine
• Cholesterol
• Crystals Associated with Liver Disorders – in s
- Tyrosine
- Leucine
- Bilirubin
• Sulfonamides
• Ampicillin
severe liver disorders, three rarely seen crystals may be found in the urine sediment:
- Tyrosine
- Leucine
- Bilirubin
Found in the urine of persons who inherit a metabolic disorder that prevents reabsorption of cystine by the renal tubules (cystinuria)
CYSTINE
Disintegrating forms may be seen in the presence of ammonia
• They may be difficult to diff
Cystine
Appear as colorless, hexagonal plates and may be thick or thin; not birefringent
Cystine
• Rarely seen unless specimens have been refrigerated, because lipids remain in droplet form
• Resembling a rectangular plate with a notch in one or more corners
Cholesterol
Associated with disorders producing lipiduria, such as the nephrotic syndrome, and are seen in conjunction with fatty casts and oval fat bodies
Cholesterol crystals
• appear as fine colorless to yellow needles that frequently form clumps or rosettes
• usually seen in conjunction with leucine crystals in specimens with positive chemical test results for bilirubin
Tyrosine
Encountered in inherited disorders of amino-acid metabolism
Tyrosine
Yellow-brown to golden yellow spheres that demonstrate concentric circles and radial striations
• They are seen less frequently than tyrosine
Leucine
• Present in hepatic disorders producing large amounts of bilirubin in the urine
• Appear as clumped needles or granules with the characteristic yellow color of bilirubin
Bilirubin
bilirubin crystals may be found incorporated into the
Matrix of casts
In disorders that produce renal tubular damage, such as viral hepatitis
Bilirubin
• Common among patients treated with UTI
• Inadequate patient hydration was and still is the primary cause of sulfonamide crystallization
Sulfonamides
• Shapes most frequently encountered include needles, rhombics, whetstones, sheaves of wheat, and rosettes with colors ranging from colorless to yellow-brown
Sulfonamides
Appear as colorless needles that tend to form bundles following refrigeration
Ampicilin
Precipitation of antibiotics is not frequently encountered
Ampicilin
