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EXAMINATION
OF
URINE
MACROSCOPIC SCREENING
To enhance the cost-effectiveness of urinalysis, many laboratories have developed protocol
whereby a microscopic examination of the urine sediments is performed on the specimens meeting
specified criteria.
Abnormalities in the physical and chemical portions of the urinalysis play a primary role in the
decision to perform a microscopic analysis thus the use of the term “macroscopic screening”.
SPECIMEN PREPARATION
Specimen should be examined while fresh or adequately preserved
o Formed elements-primarily RBCs, WBCs and hyaline casts- disintegrate rapidly,
particularly in dilute alkaline urine.
Refrigeration may cause precipitation of amorphous urates and phosphates and other non-
pathologic crystals that can obscure other elements in the urine.
Warming the specimen to 37°C prior to centrifugation may dissolve some of the crystals.
The midstream clean catch specimen minimizes external contamination of the sediments
o As with the physical and chemical analysis, dilute random specimens may cause false-
negative readings.
Care must be taken to thoroughly mix the specimen prior to decanting a portion into a centrifuge
tube.
SPECIMEN VOLUME
A standard amount of urine, usually between 10 – 15 mL, is centrifuged in a conical tube.
A 12 mL volume is frequently used because multiparameter reagent strips are easily immersed in
this volume, and capped centrifuge tubes are often calibrated to this volume.
If obtaining a 12 mL specimen is not possible, as with pediatric patients, the volume of the
specimen used should be noted on the report form.
CENTRIFUGATION
Speed of the centrifuge and the length of time the specimen is centrifuged should be consistent.
Centrifugation of 5 mins at a relative centrifugal force (RCF) of 400 produces an optimum amount
of sediment with the least chance of damaging the elements.
The RPM value shown on the centrifuge tachometer can be converted to RCF using nomograms
available in many laboratory manuals or by using the formula:
RCF = 1.118 x 10¯⁵ x radius in centimetre x RPM²
Centrifugation calibration should be routinely performed.
Use of the breaking mechanism to slow the centrifuge causes disruption of the sediment prior to
decantation and should not be used.
To prevent biohazardous aerosols; all specimens must be centrifuged in capped tubes.
SEDIMENTATION PREPARATION
A uniform amount of urine and sediment should remain in the tube after decantation.
Volume of 0.5 and 1.0 mL are frequently used.
The volume of urine centrifuge divided by the sediment volume equals the concentration factor.
The sediments concentration factor relates to the probability of detecting elements present in low
quantities and is used when quantitating the number of elements present per millilitre.
To maintain a uniform sediment concentration factor, urine should be aspirated off rather than
poured off, unless otherwise specified by the commercial system in use. Some systems provide
pipettes for this purpose.
The sediment must be thoroughly resuspended by gentle agitation. This can be performed using a
commercial-system pipette or by repeatedly tapping the tipoff the tube with the finger.
Vigorous agitation should be avoided, as it may disrupt some cellular elements.
Thorough resuspension is essential to provide equal distribution of elements in the microscopic
examination fields.
COMMERCIAL SYSTEMS
The CLSI recommends the use of commercial system together with standardization of all phases of
the methodology, including the conventional method.
Systems currently available include:
o KOVA (Hycor Biomedical, Inc., Garden Grove, CA)
o Urisystem (ThermoFisher Scientific, Waltham, MA)
o Count-10 (V-Tech, Inc., Pomona, CA)
o Quick-Prep Urinalysis System(Globe Scientific , Paramus, NJ)
o CenSlide 2000 Urinalysis System (International Remote Imaging System, Norwood, MA)
o R/S Workstation 1000, 2000, 3000 (DioSys, Waterbury, CA)
The systems provide a variety of options including:
o Capped, calibrated centrifuge tubes
o Decanting pipettes to control sedimentation volume
o Slider that control the amount of sedimentation for examination
The Cen-Slide and R/S Workstations do not require manual loading of the centrifuged specimens
onto a slide and are considered closed systems that minimize exposure to the specimen.
Cen-Slide provides a specially designed tube that permits direct reading of the urine sediments.
The R/S Workstations consist of a glass flow cell into which urine sediment is pumped,
microscopically examined, and then flushed from the system.
Routinely, casts are reported as the average number per low-power field (lpf) following examination
of 10 fields, and RBCs and WBCs, as the average number per 10 high-power fields (hpf).
Epithelial cells, crystals and other elements are frequently reported in semi quantitative terms such
as, rare, few, moderate, and many, or as 1+, 2+, 3+, and 4+, following laboratory format as to lpf or
hpf use.
Laboratories must also determine their particular reference values based on the sediment
concentration factor in use.
Converting the average number of elements per lpf or hpf to the number per millilitre provides
standardization among the various technique in use.
CORRELATING RESULTS
Microscopic results should be correlated with the physical and chemical findings to ensure the accuracy of
the report.
Specimens in which the results do not correlate must be rechecked for both technical and clerical
errors.
The amount of formed elements or chemicals must also be considered, as must the possibility of
interference with chemical tests and the age of the specimen.
CLINICAL
SEDIMENT APPEARANCE DESCRIPTION
SIGNIFICANCE
REPORTING
Lymphocytes: early
stages of renal transplant
rejection
Monocytes,
macrophages, and
histiocytes: appear
Lymphocytes, Normal urine:
vacuolated or contain
Mononuclear monocytes, <5 leukocytes
inclusions
Cells macrophages, per hpf (higher
Pyuria: increased
and histiocytes in females)
urinary WBCs- infection
or inflammation of
genitourinary system,
glomerulonephritis, LPE,
interstitial nephritis and
tumors
Epithelial
Cells
Squamous Squamous Squamous Epithelial Squamous
Epithelial Epithelial Cells: normal cellular Epithelial
Cells Cells: Largest, sloughing in female Cells: Rare,
with abundant urethra, no pathologic few, moderate
irregular significance or many per
cytoplasm and “Clue cell”- vaginal lpf
prominent infection by the COMPLETE
URINALYSIS
nuclei bacterium Gardnerella CORRELATIONS
Transitional Transitional vaginalis : Clarity
Cells Cells: Transitional Transitional
Spherical, Cells:Increased numbers Cells: Rare,
polyhedral, or singly, in pairs or in few, moderate
caudate with clumps (syncytia) or many per
central nucleus present ff. invasive hpf
RTE Cells: urologic procedures COMPLETE
Rectangular, (catherization), increased URINALYSIS
RTE Cells columnar, exhibiting vacuoles and CORRELATIONS
: Clarity, Blood if
round, oval or irregular nuclei= malignancy
cuboidal with malignancy or viral associated
eccentric infection RTE Cells:
nucleus RTE Cells:increased Average
Appear deep amount= necrosis of the number per 10
yellow in viral renal tubules hpfs
hepatitis (RTE Oval Fat Bodies: COMPLETE
cells absorb Lipiduria- damage of the URINALYSIS
CORRELATIONS
bilirubin present glomerulus caused by : Leukocyte
in filtrate as a nephrotic syndrome, esterase and
result of viral severe tubular necrosis, nitrite, color,
hepatitis) diabetes mellitus and clarity, protein,
Oval Fat trauma (bone marrow) biluribin, blood
Bodies: Highly “bubble cells” – appear Oval Fat
refractile RTE to represent injured cells Bodies:Avera
Oval Fat Cells in which the endoplasmic ge number per
Bodies reticulum has dilated hpf
COMPLETE
prior to cell death. URINALYSIS
CORRELATIONS
:Clarity, protein,
blood, free fat
droplets
May be a contamination
Few,
Cocci or bacilli, Lower or upper UTI-
Bacteria moderate, or
small size accompanied with WBCs
many per hpf
(for quantitative culture)
Candida albicans-
Small, refractile
diabetic patients (acidic,
oval structures,
glucose containing
may contain
urine), Rare ,few,
bud or not
Yeast immunocompromised moderate, or
In severe
patients and women with many per hpf
infections:
vaginal monoliasis.
branched,
Should be accompanied
mycelial forms
with WBCs
Trichomonas
vaginalis- pear
shaped
flagellate with
an undulating
membrane,
rapid darting Presence of
movement STD with vaginal ova of the
Parasites
Schistosoma inflammation parasites
haematobium-
ova of the
bladder parasite
Most common
contaminant-
Enterobius
vermicularis
Urine is toxic to
spermatozoa,
ff. sexual intercourse, Presence or
Oval, slightly masturbation, or none
tapered heads nocturnal emission (depending on
Spermatozoa
and long, Male infertility or laboratory
flagella like tails retrograde ejaculation in protocols,
which sperm is expelled varies)
into the bladder instead
of urethra
Frequently in female
Thread like urine specimen, no
structures with clinical significance Rare, few,
Mucus a low refractive (produced by glands and moderate or
index, irregular epithelial cells of lower many per lpf
appearance genitourinary tract and
RTE cells)
CASTS
The only elements found in the urinary sediments that are unique to the kidney. They are formed
within the lumens of the distal convoluted tubules and the collecting ducts, providing a microscopic
view of the conditions within the nephron. Their shape is representative of the tubular lumen, with
parallel sides and somewhat rounded ends, and they may contain additional elements present in
the filter.
APPEARANCE CLINICAL
URINE CASTS DESCRIPTION
SIGNIFICANCE
Glomerulonephritis
Pyelonephritis
Colorless, Chronic Renal
Hyaline Casts homogenous Disease
matrix Congestive Heart
Failure
Stress and Exercise
Orange-red color,
Glomerulonephritis
RBC Casts cast matrix
Strenuous Exercise
containing RBCs
Pyelonephritis
Cast matrix
WBC Casts Acute Intestinal
containing WBCs
Nephritis
Bacilli bound to
Bacterial Casts Pyelonephritis
protein matrix
Nephrotic Syndrome
Fat droplets and
Toxic Tubular
oval fat bodies
Fatty Casts Necrosis
attached to
Diabetes Mellitus
protein matrix
Crush Injuries
formed by the precipitation of urine solutes, including inorganic salts, organic compounds, and
medications
solutes precipitate more readily at room temperatures.
Majority of crystal formation takes place in specimens that have remained at room temperature or been
refrigerated specimens and often present problems
As the concentration of urinary solutes increases, their ability to remain in solution decreases, resulting
in urine formation
Freshly voided urine with crystals= high specific gravity
Organic and iatrogenic compounds crystalize easily in acidic pH
Inorganic salts are less soluble in neutral or alkaline urine
*Calcium oxalate precipitates in both acidic and neutral urine.