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Clinical Microscopy
Urinalysis

- Underused tool for the overall evaluation of renal function

- Permits a detailed, in depth assessment of renal status with an easily obtained specimen
- Serves as a quick indicator of an individual’s glucose status and hepatic or biliary function
- A waste product of metabolism fromed by the kidney’s basic functional unit “nephron”
- Three processes involved in urine formation: glomerular filtration, tubular reabsorption and tubular
secretion

Urine Composition
 Normal 95% water, 5% solutes
 diet, activity, metabolism, endocrine, body position
 Organic solutes: urea (protein, amino acid breakdown); also creatinine and uric acid
 Inorganic: chloride, sodium, potassium
o Diet makes establishing normal values hard
 Formed elements not part of ultrafiltrate may indicate disease

Urine Volume
 Determined by body’s state of hydration
 Influenced by fluid intake, nonrenal fluid loss, antidiuretic hormone (ADH) variations, excretion of
large amounts of dissolved solids (e.g., glucose)
 Usual daily volume = 1200-1500 mL
 Normal range = 600-2000 mL

DEFINITION and VOLUME DISEASE and CAUSE

Polyuria Increased urine output Diabetes insipidus, Diabetes mellitus, diuretics
>2.5L in Adult
>2.5-3mL/kg/day in children
Oliguria <1 mL/kg/hr in infants, Dehydration, vomiting, diarrhea, burns,
< 0.5 mL/kg/hr in children perspiration
< 400 mL/day in adults
Anuria Complete cessation of urine flow Kidney Damage, Decrease blood flow to the
kidney
Nocturia Increased excretion of urine at night Pregnancy

Polyuria in Diabetes Mellitus vs. Diabetes Insipidus

 Diabetes mellitus Increased volume caused by need to excrete the excess glucose not
reabsorbed from the ultrafiltrate; patients exhibit polydypsia; urine appears dilute with a high
specific gravity
 Diabetes insipidus Decreased production or function of ADH causing decreased reabsorption
of water from ultrafiltrate; urine is dilute with low specific gravity; patients also exhibit polydipsia

Specimen Collection

 Disposable, wide-mouth, and flat-bottom containers with screw caps are recommended

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 Clear containers / at least 50 mL capacity

 12mL - test

 Adhesive bags for pediatrics and large plastic containers for 24-hour specimen

Specimen Labeling

 Information on label:
 Patient’s name, ID number, date, time
 Time of collection

Specimen Rejection
 Unlabeled containers
 Non-matching labels and requisitions
 Contaminated specimens - feces, paper
 Contaminated containers
 Insufficient quantity
 Delayed or improper transport
 Ice, refrigeration
 Labs have written policies for rejection

Specimen Integrity

 Test within 2 hours of collection

 Refrigerate if testing is delayed
 Increased:color, turbidity, pH, nitrite, bacteria, odor
 Decreased: glucose, ketones, bilirubin, urobilinogen, RBCs, WBCs, casts

CHANGES IN UNPRESERVED URINE TABLE 3-2

Analyte Change Cause

Color Modified/Darkened Oxidation or reduction of metabolites

Nitrite Increased Multiplication of nitrate-reducing bacteria

Odor Multiplication of bacteria or bacterial breakdown

of urea to ammonia

pH Breakdown of urea to ammonia by urease-

producing bacteria/loss of CO2

Glucose Decreased Glycolysis and bacterial utilization

Ketones Volatilization and bacterial metabolism

Bilirubin Exposure to light/photo oxidation to biliverdin

Urobilinogen Oxidation to urobilin

Clarity Bacterial growth and precipitation of amorphous

material

Blood cells & casts Disintegration in dilute alkaline urine

Bacteria Multiplication

Specimen Preservation

 Ideal is bactericidal: inhibits urease and preserves formed elements

 Routine is refrigeration; this is a must for culture specimens
 Causes precipitation of amorphous crystals
 Must return to room temperature for chemical testing
 Commercial transport tubes are available but they must be compatible with tests

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Types of Urine Specimen/ Collection Techniques

a. First morning – routine screening, pregnancy test, detection of orthostatic proteinuria
b. Random – routine screening
c. 24-hour – quantitative chemical tests, hormone studies
d. 12-hour – Addis count
e. Afternoon specimen (2-4 pm) – urobilinogen determination
f. Fasting/Second morning – diabetic screening/monitoring
g. 2-h Postprandial – diabetic monitoring
h. Glucose Tolerance – accompaniment to blood samples in GTT
i. Drug testing specimen – collection requires stringent protocols (COC); temperature should be within
32.5- 37.7ºC; blueing agent added to the toilet water reservoir in unwitnessed collection
j. Midstream clean-catch – routine screening, bacterial culture
k. Catheterization – bacterial culture
l. Suprapubic aspiration – bacterial culture, cytology
m. Three-glass collection – diagnosis of prostatic infection

Drug specimen collection

 CHAIN OF CUSTODY – process that provides documentation of proper sample identification

from the time of collection of the receipt of laboratory results
 Required urine volume: 30-45 mL
 Temperature within 4 mins: 32.5-37.7°C
 Blue agent (dye) is added to toilet water reservoir to prevent specimen adulteration

Physical Examination
A. Color

1. Normal – varies from almost colorless, straw or light yellow to dark yellow, yellow-orange, or amber
2. Variations
Color Reason
Light yellow or yellow Normal
Straw colored/ pale yellow/ colorless Diluted; recent water intake, polyuria, DM, DI
Dark yellow Concentrated urine
Yellowish brown to green Bile pigment oxidation
Port wine Porphyrinuria
Red intact RBCs, hemoglobin, myoglobin, porphyrins,
beets, menstrual contamination

Brown/black methemoglobin, homogentisic acid, melanin,

argyrol, methyldopa, levodopa, metronidazole
Amber/ orange bilirubin, acriflavine, phenazopyridine,
nitrofurantoin, phenindione

B. Odor
1. Normal – faint aromatic due to volatile acids; becomes ammoniacal as the specimen stands
2. Variations
Odor Reason
Ammoniacal (freshly voided) UTI
Rancid tyrosinuria
Maple syrup/ caramel-like MSUD
Sulfur odor cystine disorders

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Fruity/ sweet diabetes ketoacidosis

Mercaptan asparagus, garlic, and eggs
Mousy PKU
Sweaty feet Isovaleric acidemia
Rotting fish Trimethyl aminuria
Fecaloid Rector vesicular fistula
Cabbage/ hops Methionine malabsorption
bleach contamination

C. Transparency
1. Normal: Clear – no visible particulates, transparent
2. Variations:
Hazy – few particulates, print easily seen through urine
Cloudy – many particulates, print blurred through urine
Turbid – print cannot be seen through urine
Milky – may precipitate or be clotted

Chemical Examination
A. Specific Gravity
Normal Value: 1.005- 1.030 depend on the patient’s degree of hydration
2. Variations:
Clinical Correlation
Increase SG DM, CHF, dehydration, adrenal insufficiency,
liver disease, nephrosis
Decreas SG DI, pyelonephritis, glomerulonephritis

B. pH
Refers to the negative logarithm of the hydrogen ion concentration
Normal pH of a random urine : 4.5-8.0
a. Acidity ( pH <7)
metabolic and respiratory acidosis
acid-promoting medications (ammonium chloride, madelic acid)
b. Alkalinity (pH >7)
metabolic and respiratory alkalosis
alkaline-promoting medications (potassium citrate)

C. Protein
Normal: (<30 mg/dL or <150 mg/day; Negative rgt strip test)
Variations:
Degrees of proteinuria:
a. Mild – < 1.0 g/day
b. Moderate – 1.0-4.0 g/day
c. Heavy – > 4.0 g/day
Types of proteinuria:
a. Pre-renal – intravascular hemolysis; muscle injury; severe infection and inflammation; multiple
myeloma
b. Renal (glomerular) – diabetic nephropathy, amyloidosis, glomerulonephritis, autoimmune disorders,
toxic agents, hypertension, strenuous exercise, pre-eclampsia, dehydration, orthostatic proteinuria
c. Renal (tubular) – Fanconi syndrome, toxic agents, severe viral infections
d. Post-renal – lower UTI; injury or trauma; menstrual contamination; prostatic fluid; spermatozoa; vaginal
secretions

D. Glucose
Normal: (<15 mg/dL; Negative rgt strip test)
Variations:
Types of Glucosuria:
a. Hyperglycemia-associated – diabetes mellitus, endocrine disorders, pancreatic disorders, CNS
disorders, disturbance in metabolism, liver disease, drugs, gestational diabetes mellitus

b. Renal-associated – renal tubular dysfunction, tubular necrosis, Fanconi syndrome, osteomalacia,

pregnancy

Microscopic Examination
Steps:
1. 10-15mL urine (Average 12mL)
2. Centrifuge at 400 RCF for 5mins
3. Decant urine (0.5 or 1.0mL remains)
4. Transfer 20uL (0.02mL) sediment to glass slide with 22x22 coverslip
5. Examine microscopically, 10LPF, 10HPF under reduced light
 Initial focusing: low power, reduced light
 Focus on epithelial cell, not artifacts that are in a different plane
 Use fine adjustment continuously for best view

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 Low power: casts, general composition

 Scan edges for casts with glass slide method
 High power: identification

Microscope Function
Bright- field microscope For routine urinalysis
Phase- contrast microscope Increases refractive index
Polarizing microscope Identification of cholesterol in oval fat
bodies, fatty cast and crystals

Cellular elements
a. RBC – Reported as average count/HPF
-seen in cases: glomerulonephritis, severe exercise, menstrual blood contamination, renal calculi,
malignancy

b. WBC - Reported as average count/HPF

-seen in: urinary tract infection or inflammation

c. Epithelial cells – reported qualitatively (rare,few,moderate, many)

-cells sloughed off the linig of nephrons and urinary tract

d. Cast
-formed primarily within distal convoluted tubule and collecting duct
Hyaline cast - Seen with other pathological casts in cases of AGN, CGN, APN, and CHF
Red blood cell cast – seen in glomerulonephritis and damage to the capillary structure of the nephrons
White blood cell cast - Seen in pyelonephritis (+WBCs and bacteria) and interstitial nephritis
(+eosinophils)
RTE cell cast - Advanced tubular destruction, associated with exposure to toxic agents
Granular cast - Indicates stasis of urine flow
Waxy cast - Extreme urine stasis, indicating CRF; final phase of cast degeneration
Broad cast - Extreme urine stasis and destruction of the tubular walls
Fatty cast - Seen in lipiduria in conjunction with oval fat bodies and free fat droplets

e, Crystals
ACIDIC URINE
 Uric acid – polymorphic; Increased in gout, leukemia, and Lesch-Nyhan syndrome
 Amorphous urates – sand grain like;; Commonly seen in refrigerated specimens
 Calcium oxalate - envelop shaped Ethylene glycol poisoning, renal Calculi

ALKALINE URINE
 Amorph. phosphates –sand shaped like; Seen in refrigerated specimens
 Calcium phosphate colorless thin prisms, plates, needles- Common constituent of renal calculi
 Triple phosphate – coffin lid; Presence of urea-splitting bacteria (e.g. Proteus, Pseudomonas)
 Ammonium biurate

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