URINANLYSIS & BODY FLUIDS (HLD 22403)

URINE MICROSCOPIC SEDIMENT EXAMINATION By Mr.Hanan

INTRODUCTION
The third part of urinalysis the microscopic examination of urinary sediment. The purpose is to detected and to identify insoluble material present in the urine. The blood ,kidney , lower genitourinary tract , and external contamination all contribute formed elements to the urine. These include RBCs, WBCs, epithelial cells , casts ,bacteria, yeast , parasites , mucus , spermatozoa, crystals and artifacts. Some of these components are of no clinical significance and others are considered normal unless present in increased amounts. Examination of urine sediment must include both identification & quantification.

MICROSCOPIC EXAMINATION
Qualitative technique: The urine must be freshly voided Examined without excessive delay in order to prevent cellular deterioration. Cellular debris from the urethral meatus and secretions from the vagina may contaminate the urine specimen.

Figure 28.1

 10-15 ml of urine ----from freshly mixed urine specimen and centrifuged at a standard speed, usually 1500 to 2000 rpm for 5 minutes. This is sufficient to bring to the bottom casts, pus cells, blood and crystals. For bacteria however a higher speed of 3,000 rpm is required. The sediment resuspended in 1 ml of the same fluid.
A drop of resuspended sediment is placed directly on a microscope slide and covered with a cover slip.

low power- Casts tend to congregate at the edges of the cover slip. A minimum of 10 15 high power fields should be scanned for this examination.
Red blood cells, leucocytes, epithelial cells--- per high power field(/hpf); casts --- per low power fields(/lpf). Other elements such as bacteria, parasites, crystals and spermatozoa are reported as well

NORMAL SEDIMENT
Normal sediment contains a limited number of formed elements. It can be divided into two classes.

Unorganized sediment
Unorganized sediment - these are the crystals of various substances present in the urine and they vary with the pH of the urine .Crystals of normal urine is formed as the specimen cools

Organized sediment

URINARY CRYSTALS Crystals are frequently found in the urine & are rarely of clinical significance. They may appear as :
Geometrically formed or as amorphous material.

Primary reason of detecting crystals is to detect the abnormal types that may represent disorders.

URINARY CRYSTALS
CRYSTAL FORMATION

Crystals are formed by the precipitation of urine solutes, including :

Organic compounds, inorganic salts & medication (iatrogenic compounds).

Precipitation is subject to changes:

In temperature Solute concentration pH

which affect solubility

 Solutes precipitate more readily at low temperatures. Crystals formation takes place in specimen that have remained in room temperature or refrigerated prior to testing. A valuable aid in the identification of crystals is the pH of the specimen because it determines the type of chemicals precipitated.

URINARY CRYSTALS ACIDIC URINE Common crystals seen in acidic urine are
Urates consisting of amorphous urates, Uric acid , & sodium urates.

Microscopically urate crystals appear yellow to reddish brown & are normal crystals found in acidic urine

 Amorphous urates yellow brown granules. Appear like clumps resembling granular casts. Found in specimen that has been refrigerated. Amorphous urates appear as
fine pink or brownish-tan granules. Accumulation of uroerythrin on the surface of the granules is the cause of the pink color They are salts of uric acid (lower pH) and are normally found in acid or neutral urine. pH greater than 5.5.

URINARY CRYSTALS URIC ACID CRYSTALS

Uric acid crystals exhibit extreme pleomorphism in size and in shape. They appear readily in acid urine allowed to stand at room temperature.

Increased amounts- increase levels of purines & nucelic acid in patients with leukemia or receiving chemotherapy, Lesh-Nyhan syndrome (disorder of purine metabolism) & sometimes in patients with gout.

 Uric acid crystals

Notice the whetstone, not hexagonal , shape that differinciate uric acid crystal with cystine crystals extreme pleomorphism- including rhombic,4sided flat plates (whetstone )wedges &rosettes Color yellow brown but may also appear colorless

URINARY CRYSTALS
CALCIUM OXALATE CRYSTALS Seen in acidic urine but also found in neutral urine. Most common form of calcium oxalate is the dihydrate- colorless, octahendral or as 2 pyramids joined together. Monhydrate- dumbell shape. Calcium oxalate- sometimes seen in clumps attached to mucous-may resemble casts. Findings of calcium oxalate clumps formation of renal calculi-compose of calcium oxalate

 Also found with food high in oxalic acid (tomatoes, asparagus & ascorbic acid) oxalic acid- end product of ascorbic acid. Pathological significance-very noticeable monohydrate form in cases of ethylene glycol poisoning .Massive amounts

 commonly appear octahedral, dumbbell shape

URINARY CRYSTALS ALKALINE URINE

Phosphates- majority seen in alkaline urine. Amorphous phosphates-granular +/- to urates. Large quantities- after refrigeration form white precipitate-does not dissolve on warming. Triple phosphates,& calcium phosphates. Others are calcium phosphates & ammonium biurrates.

URINARY CRYSTALS
AMORPHOUS PHOSPHATES
Amorphous phosphates appear in neutral to alkaline urine as fine, colorless or slightly brown granules. White precipitate is observed on centrifugation. (Brightfield microscopy, 160X magnification.)

URINARY CRYSTALS
TRIPLE PHOSPHATE
Triple phosphate crystals, viewed here with interference-contrast microscopy (160X magnification), resemble prisms or "coffin lids". They are found normally in alkaline or neutral urine. They are colorless, no clinical significance-seen in highly alkaline urine associated with presence of urea spliting bacteria

URINARY CRYSTALS
CALCIUM PHOSPHATE
Calcium phosphate crystals assume various forms including the rosette and pointed finger forms shown here with bright field microscopy (160X magnification). They appear most often in alkaline urine. Common constituent of renal calculi

URINARY CRYSTAL
CALCIUM CARBONATE
Calcium carbonate crystals are small and colorless and appear in alkaline urine as granules or as small dumbbells. They appears as clumps- resembels amorphous material. Formation of gases- when added acetic acid , to differentiate Also birefringent which differentiate from bacteria No clinical significance.

 Calcium carbonate crystals are small and colorless and appear in alkaline urine as granules or as small dumbbells. Bacteria are also present in this field (brightfield microscopy, 250X magnification).

URINARY CRYSTAL AMONIUM BIURATE

Color yellow brown seen in acidic urine They are the only urate crystals that appear in alkaline urine. Describe as thorny apples- presences of spicule covered sphere

 Encountered in old specimens associated with the presence of ammonia produce by urea splitting bacteria. Dissolves at 60c convert to uric acid crystals when glacial acetic acid is added. Ammonium urate crystals are easily distinguished by their golden brown color and "thorn apple" shape. They are seen here under bright field microscopy (160X magnification).

URINARY CRYSTAL ABNORMAL CRYSTALS

Cystine crystals- person inherit a metabolic disorder. Cystinuria-prevents reabsorption of cystine by the renal tubules. Tendency to form renal calculi Rarely seen, these crystals are found in acid urine and are seen as thin, colorless, hexagonal plates.

 Only thick cystine have polarizing capability- mistaken with uric acid . Conformation using cynaide nitroprusside test.

URINARY CRYSTAL ABNORMAL CRYSTALS

Cholesterol crystals rarely seen unless specimen has been refrigerated- lipids remain in droplet form. Observation-rectangular plate in shape with notch in or more corners . Disorders producing lipiduria such as nephrotic syndrome. Seen usually with fatty cast & oval fat bodies

 Cholesterol crystals are seen in the center of this field with squamous epithelial cells on either side. Cholesterol crystals are found in acid or neutral urine. They appear as regular or irregular transparent plates. They may occur singly or in large numbers. Usually one or more corners are cut off or notched, justifying their description as "stair step crystals".

URINARY CRYSTAL ABNORMAL CRYSTALS (LIVER DISODERS)

Tyrosine crystals are not normally found in urine. They are products of protein metabolism and appear in urine of people with tissue degeneration or necrosis (acute liver disease, severe leukemia, typhoid fever, and smallpox). They are present only when urine is acid.

 Colorless to yellowish brown, needle shaped crystals and have a fine silky appearance. The needles may be single or arranged in sheaves or rosettes. Tyrosine crystals usually appear in urinary sediment together with leucine crystals

URINARY CRYSTAL ABNORMAL CRYSTALS (LIVER DISODERS)

Leucine crystals are not normally found in urine Appear in urine in association with tyrosine and are manifestations of the same clinical conditions. When found, leucine crystals are in acid urine in the form of spheroids with concentric striations. They are dense, highly refractive and appear as yellowish brown bodies.

URINARY CRYSTAL ABNORMAL CRYSTALS (LIVER DISODERS)

Bilirubin crystals- In hepatic disorders. Appears as clump needles or granules with yellow color Disorders that produce renal tubular damage, viral hepatits , bilirubin crystals may be found incorporated into the matrix of casts.

URINARY CRYSTAL ABNORMAL CRYSTALS

Sulfonamide crystals form primarily in acid urine. The shape and color of these crystals are extremely variable, depending on the particular sulfonamide being administered to the patient. The most common forms encountered include rosettes, fan shapes and those resembling shocks of wheat.

Sulfa crystals have pathologic significance, since they tend to form renal calculi that may damage renal tubules.

 Sulfoamide- In patient being treated for UTI. Inadequate hydration is the primary cause of sulfoamide crystallization. Can suggest-possibility of tubular damage if crystal are forming in the nephrones

 forms encountered include rosettes, fan shapes and those resembling shocks of wheat.

URINARY CRYSTAL ABNORMAL CRYSTALS

Ampicilin crystals rarely encounteredmassive dose of ampicilin compound with poor hydration. Knowledge of the patient Hx can aide the identification.

ORGANIZED SEDIMENT

Organized Sediment
The components of organized sediment include casts, red blood cells, white blood cells, epithelial cells, bacteria, yeast, parasites, spermatozoa and artifacts.

CASTS
Casts are formed in the tubules and is composed of proteinaceous material. They are washed out by the glomerular secretion into the collecting tubules and the bladder. They are cylindrical in shape with round or broken ends with uniform diameter but varying in length. They require acidic conditions, high salt concentration, reduced urine flow and protein to be formed.

 Practically all casts have a hyaline matrix, which may or may not contain inclusions such as desquamated cells.
The casts are named according to the matrix of the inclusions contained in them e.g. red blood cell casts. Casts Suggest Kidney pathology.

Casts can be made up of Protein, lipid, cells or mixed

HYALINE CASTS
Are colorless, semi-transparent and occasionally refractile cylinders and are soluble in acetic acid. They are seen when there is damage to the glomerular capillary membrane, permitting leakage of proteins through the glomerular filtrate.

They are seen in fever, orthostatic proteinuria, and emotional stress or strenuous exercise.

Granular casts are casts containing large or fine granules embedded in coagulated protein. They are not found in normal urine and their presences indicate pyelonephritis. They are also seen in chronic lead poisoning. Epithelial casts are formed of fused desquamated tubular cells. They are coagulated protein in which are embedded desquamated epithelial cells from the renal tubules .They are seen in diseases where there is damage to the tubular epithelium as in nephrosis, eclampsia, amyloidosis and heavy metal poisoning.

Red Blood Cell Casts: are casts with red blood cells embedded in the coagulated protein in the tubule. Their presences indicate acute inflammation or vascular disorder in the glomerulus causing hematuria. They are seen in pathological conditions such as acute glomerulonephritis, renal infarction and collagen vascular disorder.

WHITE BLOOD CELL CASTS

Indicative of inflammation or infection, pyelonephritis

acute allergic interstitial nephritis,

nephrotic syndrome, or post-streptococcal acute glomerulonephritis

FATTY CASTS
Formed by the breakdown of lipid-rich epithelial cells, these are hyaline casts with fat globule inclusions

They can be present in various disorders, including nephrotic syndrome, diabetic or lupus nephropathy, Acute tubular necrosis

WAXY CASTS
Waxy casts suggest severe, longstanding kidney

disease such as renal failure(end stage renal disease).

They appear fragmented with jagged ends &have notches at the side. Supravital stain waxy cast stain a homogenus dark pink

Sowhat is a cast??? Lets Review

Protein based cylindrical molds of the renal tubule Form in distal tubules and collecting ducts Result of damage to the renal tubule Can contain cells and other material Dehydration and acidic urine especially predisposes to cast formation

Types of casts
Acellular casts Hyaline casts Granular casts Waxy casts Fatty casts Crystal casts Cellular casts Red cell casts White cell casts Epithelial cell cast

ACELLULAR CASTS
Appears colorless in undstained sediment , refractive index, sternheimer-malbin stain produce pink color.l Normal parallel sides, rounded ends, cylindroid forms,&wrinkled or convoluted shapes indicate aging of the cast matrix.

Granular Casts

Granular cast
Non-specific but usually pathologic Usually the granules are from the degeneration of cellular casts

Waxy cast
Thought to result from the degeneration of cellular casts

FATTY CAST
The cast matrix contain a few or many oil droplet. Intact

oval fat bodies may be attach to the matrix.

Stain with Sudan iii or Oil Red O Fat Stain

CELLULAR CAST RED CELL CAST

Almost always associated with glomerulonephritis or vasculitis Virtually exclude extra-renal causes of bleeding

RBC

EPITHELIAL CASTS IN URINE:

TUBULAR EPITHELIAL CAST

WBC in Urine

WBC

WBC CAST URINE:

WHITE BLOOD CELL CAST

Seen in interstitial disease most commonly Also seen in glomerulonephritis

White blood cell cast

This is a white blood cell cast with intact leukocytes. The leukocytes have multilobed nuclei. (Bright field microscopy)

EPITHELIAL CELLS
Epithelial Cells: Normally a few epithelial cells occur in the urine . A marked increase in these cells in the urine is seen destruction of the tissues in the urinary tract

Microscopic Examination
Squamous Cells

Squamous epithelial cell in urine

This is a squamous epithelial cell under brightfield microscopy (250X magnification).Squamous epithelial cells are characterized by a small, round, central nucleus with a large amount of granular or wrinkled cytoplasm (a "fried egg" appearance).

Microscopic Examination
Tubular Epithelial Cells

Renal Epithelial Cells

A group of attached renal tubular epithelial cells are seen in the center of this slide. The background contains white blood cells and red blood cells (bright field microscopy, 250X magnification)

Microscopic Examination
Transitional Cells

Microscopic Examination
Transitional Cells

Microscopic Examination
Bacteria & Yeasts

Bacteria
Bacteriuria More than 10 per HPF

Yeasts
- Candidiasis Most likely a contaminant but should correlate with clinical picture.

Bacteria and white blood cells

This is a low power view (100X magnification) of urine with bacteria and several leukocytes in the field. Bacteria are bacillary and diffusely scattered throughout. The urine is stained with Sternheimer-Malbin stain.

White blood cells and bacteria

These are white blood cells and bacteria found in urinary sediment using interference-contrast microscopy. The cell in the center has a pseudopod extending from its cytoplasm indicating amoeboid motion.

Microscopic Examination
LE Cell

Microscopic Examination
Yeasts

Budding yeast cells

Budding yeast are visible on the left side of this slide with a squamous epithelial cell on the right. There are no segmented neutrophils seen. This suggests the yeast are a contaminant and not causing a urinary tract infection (bright field microscopy, 200X).

Mucus

This slide shows mucus in urine with two entrapped white cells. There are also two red cells present, one within the mucus and one above it. Mucus fibers are fibrillar and delicate. They have a very low refractive index. (Bright field microscopy, 160X magnification.)

URINARY SEDIMENT ARTIFACTS

Contaminants that are found in the urine Specimen collected improperly or in dirty containers. Most frequent: Oil droplet Starch Pollen Grains and fibers

Fecal material in urine

Fecal material can usually be identified by its brown coloration, and the assortment of bizarre shapes and sizes of component elements. Fecal contamination of urine most often occurs in incontinent babies or elderly persons. (Brightfield microscopy, 40X magnification)

Talc in urine

Talcum powder, commonly used as a dusting powder to prevent chafing or heat rash, appears as a contaminant in urine as crystals. (Brightfield microscopy, 128X magnification.)

Starch in urine

A derivative of cornstarch is used as a dusting powder for surgical gloves. It can enter the urine during catheterization. The starch granules are usually identifiable by their size, shape and high refractive index. (Brightfield microscopy, 100X magnification.)

Cotton fiber in urine

A cotton fiber is easily identified by its size. A cotton fiber is seen here with squamous epithelial cells and white blood cells.(Brightfield microscopy, 51X magnification.)

Fiber in urine

This slide depicts a fiber artifact found in urine under brightfield microscopy at 200X magnification.

 Home work Mixed cast and oval fat bodies