URINARY SEDIMENT

Elias Bonya
B-Tech, DBMS
2017
STAINS USED IN URINALYSIS

 Increase the overall visibility of sediment

elements being examined using bright field
microscopy by changing their refractive
index.
 Also imparts identifying characteristics to
cellular structures, such as the nuclei,
cytoplasm, and inclusions.
SUPRAVITAL STAINS
1. STERNHEIMER-MALBIN STAIN

 Consists of crystal violet and safranin O

 Available commercially under a variety of
names, including Sedi-stain, and KOVA stain.
 Commercial brands contain stabilizing chemicals
to prevent the precipitation that occurred in the
original stain
 Absorbed well by WBCs, epithelial cells, and
casts, providing clearer delineation of structure
and contrasting colors of nucleus and cytoplasm
RECIPE OF THE STAIN

 Urine must be absolutely fresh. "Glitter cells"

are neutrophils, swollen in a hypotonic urine,
whose neutrophilic granules demonstrate
rapid Brownian movement against
motionless nuclei
SOLUTION 1

➢ crystal violet 3 g
➢ ammonium oxalate 0.8 g
➢ 95% ethanol 20 mL
➢ distilled water 80 mL
SOLUTION 2:
➢ safranin O 1 g
➢ 95% ethanol 40 mL
➢ distilled water 400 mL
FINALIZING THE RECIPE

 Mix, then filter, 3 parts of solution 1 and 97 parts

of solution 2.
 The mixture keeps for three months,
 Filtering every two weeks (the stock solutions
keep indefinitely).
 To use, add one or two drops of stain to 1 mL of
urine sediment suspension, and examine under
the microscope, preferably with an oil immersion
lens.
2. TOLUIDINE BLUE

 0.5%
 Metachromatic stain
 Provides enhancement of nuclear detail
 Useful in the differentiation between WBCs and
renal epithelial tubular epithelial cells
 Also used in examination of cells from other
body fluids
 Nuclear detail is also enhanced by the addition
of 2% acetic acid to the sediment.
LIPID STAINS

 Oil red O
 Sudan III
 Polarizing microscopy can be used
 Triglycerides and neutral fats stain orange-
red
 Cholesterol does not stain but is capable of
polarization
 The three elements occur concurrently in the
sediment
GRAM STAIN

 Primarily used in microbiology section

 Role in urinalysis limited to the identification
of bacterial casts, which can be easily
confused with granular casts.
 Dried, heat-fixed preparation of the urine
sediment must be used
ACETIC ACID

 Not a stain
 Useful in differentiation of WBCs from RBCs
 2% used
 A few drops added to the sediment in the test
tube, or flowed under the cover-slip of a
mounted urine sediment
 Lyses' RBCs, accentuates nucleus of WBCs,
and epithelial cells
 Crystals are also dissolved
HANSEL’S STAIN

 Special eosinophil stain

 Contains methylene blue and eosin-Y in
methanol
 Used for detection of eosinophils
 May also be used in nasal smears to detect
allergic rhinorrhea
 Urine sediment should be prepared by
cytocentrifugation
RECIPE

❖ 1. 1:200 eosin stain

❖ 0.30 g eosin
❖ 60.00 ml methyl alcohol
❖ 2. 1:100 Methylene blue stain
❖ 0.60 methylene blue
❖ 60.00 ml methyl alcohol
❖ 3. Distilled water
❖ 4. 95% ethanol
METHOD

1. Flood an air dried slide with eosin stain and

allow to stand for 1 minute.
2. Add an equal volume distilled water for 1
minute.
3. Drain and flood slide with distilled water
until all the stain is removed.
4. Flood slide with 95% ethanol and then
drain.
METHOD

5. Stain immediately with methylene blue for 1

minute.
6. Add an equal volume distilled water until all
the stain is removed.
7. Flood slide with distilled water until all the
stain is removed.
8. Flood slide with 95% ethanol and air dry.
9. Examine under oil immersion
GRADING

 Grade 1: No cells seen

 Grade 2: Only occasional eosinophils on smear.
 Grade 3: Present but scanty and scattered
throughout smear.
 Grade 4: Approximately ¼ cells on smear
eosinophils.
 Grade 5: Approximately ½ cells on smear
eosinophils.
 Grade 6: Almost all cells on smear eosinophils.
PRUSSIAN BLUE STAIN

 For investigation of episodes of

hemoglobinuria- for confirmation of
hemosiderine granules.
 Yellow-brown granules may be seen in renal
tubular epithelial cells and casts or free-
floating in the urine sediment
 Hemosiderine granules stain blue color
RED BLOOD CELLS

 Appear as smooth, non-nucleated, biconcave

discs measuring approximately 7μm in
diameter.
 Hematuria is the presence of red blood cells
in urine
 The degree of hematuria vary from a frankly
bloody specimen on gross examination to a
specimen that shows no change in color.
RED BLOOD CELLS

 Not easy to find under the microscope

 Careful examination required
 Continual refocusing needed
 Phase contrast microscope very useful,
detects even after the cell is hemolysed
 Seen as pale yellowish orange in fresh urine
IN HYPERSTHENURIC URINE

 Red cells appear crenated or irregularly

shaped.
 In hyposthenuric urine, they lyse, hence
presence of ghost cells
WHY DIFFICULTY TO SEE

❖ Variations in size
❖ Lack of characteristic structures
❖ Close resemblance to other sediment
constituents
❖ May be confused with oil droplets, yeast
cells, and air bubbles.
DIFFERENTIATION

 Oil droplets and air bubbles are highly refractile

when the fine adjustment is focused up and
down. They may also appear in a different plane
than other sediment constituents.
 Yeast cells will usually exhibit budding.
 Acetic acid used to differentiate from WBCs and
yeasts, oil droplets.
 Supravital stains may also be helpful
DYSMORPHIC RED BLOOD CELLS

 Poor shape of RBCs,, fragmented, or having

protrusions.
 Associated with glomerular bleeding
 Number and appearance should be
considered- ?abnormal concentration.
DYSMORPHIC RED BLOOD CELLS

 Mostly associated with glomerular bleeding –

appear to be acanthocyte with multiple
protrusions,
 Wright’s stain – hypochromic, better
delineation of cellular blebs and protrusions
CLINICAL SIGNIFICANCE

➢ Red blood cells can enter the urine from the

vagina in menstruation
➢ trauma of bladder catherization.
 Red blood cells in the urine otherwise may be
due to many causes including
✓ Kidney damage,
✓ Tumors eroding the urinary tract,
✓ Stones,
✓ Urinary tract infections.
APPEARENCE
 Note the irregular outlines of many of these RBC's,
compared to two relatively normal RBC's at the
center left of the right panel. These abnormal RBC's
are dysmorphic RBC's.
 WHITE BLOOD CELLS
 Few are normal
 Reference values vary
 More than a few is abnormal
 Usually refers to neutrophils (PMN), unless
otherwise specified.
 However, any type of cell may be found.
 Presence of lymphocytes and eosinophils is
of particular diagnostic significance
 PYURIA

 Increased numbers of leukocytes found in

urine
 May cause cloudiness of the specimen
 Severe will cause urine to be milky
 Under the microscope the leukocytes may
appear singly or in clumps.
 ORIGIN OF WBCS IN DISEASE

 Generally, their presence indicates

inflammation at some point along the
urogenital tract.
➢ Within the kidney
➢ Lower urinary tract e.g. bladder, urethra
 NEUTROPHILS

 Predominant WBC in urine

 Easier to identify – contain granules
 In hypotonic solution they swell, Brownian
movement produces sparkling appearance,
and they are referred to as glitter cells
 When stained with Sternheimer-Malbin stain,
the glitter cells stain light blue as opposed to
the violet color usually seen with neutrophils.
WBCs
NEUTROPHILS
PMNs
 EOSINOPHILS

 Associated with drug-induced interstitial

nephritis
 Small numbers may be seen in urinary tract
infection, and renal transplant rejection
 Morphologically similar to neutrophil, difficult
to differentiate especially with a wet
preparation, under both bright field and
phase contrast illumination.
 Larger than neutrophils
 EOSINOPHILS

 Oval and elongated in urine

 Cytoplasmic granules may not be prominent,
presence of two or three distinct lobes of the
nucleus with fresh specimen is helpful.
 Wrights stain might be used, but may not
give good staining as the cells are stained in
blood.
 EOSINOPHILS

 Hansel’s stain is helpful

 Detection is important because the treatment
of drug-induced interstitial nephritis is fast
and effective, namely discontinuation of the
drug.
 Example of the drugs is penicillins.
 With routine and cytocentrifugation, 100 to
500 cells is determine.
 1% percent is significant
EOSINOPHILS IN WRIGHT’S
STAIN
 MONONUCLEAR CELLS

 Lymphocytes, monocytes, macrophages,

and histiocytes may be present in small
numbers and are usually not identified in the
wet preparation urine microscopic
examination.
 LYMPHOCYTES

 Because of small size, may resemble RBCs.

 May be seen in increased numbers in the
early stages of renal transplant rejection.
 Monocytes, macrophages, and histiocytes
are large enough and may appear
vacuolated or contain inclusions
 UNIDENTIFIED MONONUCLEAR
CELLS

 Those that cannot be identified as epithelial

cells should be referred cytodiagnostic urine
testing.
 Wright’s stain is used
MONOCYTES, HISTIOCYTES, AND
MACROPHAGES

 Have abundant cytoplasm, are vacuolated,

and granulated
 Positive with leukocyte esterase, however,
the sensitivity of the strips may be insufficient
to detect these cells.
MONOCYTES AND HISTIOCYTES

 Are associated with chronic inflammation and

radiation therapy.
 MACROPHAGES

 May be present with inclusions within the

cytoplasm.
 The inclusions include, ingested fat,
hemosiderine, red cells, or crystals.
 Cytocentrifugation and staining with Wright’s
stain is helpful for confirmation.
 CONCERN FOR IDENTIFICATION
OF WBCs

 Differentiation of mononuclear cells and

disintegrating neutrophils from renal tubular
epithelial (RTE) cells
 RTE cells are usually larger than WBCs and
more polyhedral in shape with eccentrically
located nucleus
 MOVING WBCs

 WBCs in the amoeboid motion may be

difficult to distinguish from epithelial cells
because of their irregular shape.
 Supravital staining or the addition of acetic
acid can be used to enhance nuclear detail.
 CLINICAL SIGNIFICANCE OF
PYURIA

➢ Renal inflammation
➢ Renal infection
➢ Pyelonephritis
➢ Chronic renal disease
➢ Acute glomerulonephritis
➢ Lupus erythematosus
➢ Interstitial nephritis
➢ Tumors
 EPITHELIAL CELLS

 Derived from the linings of the genitourinary

system
 Not unusual to find them in urine – represent
sloughing of old cells
 Large numbers, and abnormal forms -
abnormal
 Three types
 THREE TYPES

❖ Squamous
❖ Transitional (urothelial)
❖ Renal tubular (RTE)
 COMMON SOURCE OF
EPITHELIAL CELLS

 Layer of epithelial cells closest to the lumen

organs such as urethra and bladder (besides
contaminating cells of the male and female
tracts) is continually sloughed off (exfoliated)
into the urine and replaced by cells
originating from deeper layers
SQUAMOUS EPITHELIAL CELLS
 SQUAMOUS EPITHELIAL CELLS

 Line the urethra and bladder trigone in the

female, and the distal portion of the male
urethra.
 They also line the vagina,
 Found in urine as a result of perineal or
vaginal contamination in females or foreskin
in males.
 SQUAMOUS EPITHELIAL CELLS

 Most commonly encountered

 Least significant
 Divided into intermediate and superficial
squamous epithelial cells
 SQUAMOU\S EPITHELIAL CELLS

 Very large, flat, with thin layer of cytoplasm, and

a single distinct nucleus
 The nucleus is about the size of RBC or
lymphocyte
 About 5 – 7 times the size of RBC about
(30 – 50 μm)
 May be rectangular or round,
 May also be cigar shaped – mistaken for casts
 STAINING

 Easily recognized until they begin to

degenerate, when they may appear as
amorphous mass.
 Stain purple nucleus and abundant of pink
cytoplasm or violet cytoplasm with
Sternheimer-Malbin stain
 CLINICAL SIGNIFICANCE

 Not of clinical significance unless in large

numbers
 Vaginal secretions or exudates, sheets of
squamous epithelial cells accompanied by
many rod-shaped bacteria or yeasts, or both
may be seen.
 Possible contamination of the specimen with
skin flora.
 CLUE CELLS

 Squamous epithelial cells of vaginal origin

 Covered or encrusted with a bacterium,
Gardenerella vaginalis
 Usually searched for in wet mounts of
vaginal swabs
 Their presence indicates bacterial vaginitis
 GARDENERELLA VAGINALIS

 Coccobacilli
 Give cytoplasm of squamous epithelial cells
a characteristic refractile, stippled, granular
appearance with shaggy or bearded cell
borders.
 IDENTIFICATION OF CLUE CELL

 Most, but not necessarily all, of the cell

surface should be covered with bacteria, and
the bacteria should extend beyond the
cytoplasmic margins
 The occasional keratohyaline granules in the
cytoplasm of squamous epithelial cells
should not be mistaken for clue cells.
 TRANSITIONAL EPITHELIAL
CELLS

 Smaller than squamous epithelial cells

 Appear in several forms
 The differences are caused by the ability of
transitional epithelial cells to absorb large
amounts of water.
 Cells in direct contact with urine absorb
water, becoming spherical and much larger
than the polyhedral and caudate cells
 TRANSTIONAL EPITHELIAL
CELLS

 Transitional epithelial cells originate from the

renal pelvis, ureters, urinary bladder and/or
urethra.
 Their size and shape depends on the depth
of origin in the mucosa.
 Most often they are round or polygonal; less
commonly pear-shaped, tailed, or spindle-
shaped.
 EPITHELIAL CELLS

 They are generally somewhat smaller and

smoother in outline than squamous cells, but
larger than WBC.
 They may develop refractile, fatty inclusions
as they degenerate in older specimens
 EPITHELIAL CELLS

 In cleanly-collected normal samples,

transitional cells are few, and present as
single cells or small clusters
 Specimens collected by catheter sometimes
contain large sheets of cells scraped off
during passage of the catheter.
 FORMS

 Have distinct, centrally located nuclei

 Transitional epithelial cells are identified and
enumerated using high-power magnification.
 Increased numbers seen singly, in pairs, or
in clumps (synctia) are present following
invasive urologic procedures such as
catheterization and are of no clinical
significance.
 TRANSITIONAL EPITHELIAL
CELLS

 In inflammatory conditions causing

hyperplasia of the urinary mucosa, larger
numbers/clusters may exfoliate. In such
cases, differentiation from neoplastic
transitional cells may be difficult.
 SPHERICAL FORMS

 Sometimes difficult to distinguish from RTE

cells.
 The presence of a centrally located than
eccentrically placed nucleus and supravital
staining can aid in the differentiation.
TRANSITIONAL EPITHELIAL
CELLS
 RENAL TUBULAR EPITHELIAL
CELLS

 (RTE) cells
 Vary in size depending on the area of renal
tubules from which they originate.
 The size tends to diminish as they progress
from large, rectangular cells in the proximal
convoluted tubule to cuboidal or columnar
cells not much larger than WBCS in the
collecting duct.
 RENAL TUBULAR CELLS

 Cells from the proximal convoluted tubule

have coarse granulated cytoplasm, whereas
those from the collecting ducts are very finely
granulated.
 Cells from the collecting ducts that occur in
groups of three or more are called renal
fragments and may indicate more severe
renal damage.
 RENAL TUBULAR EPITHELIAL
CELLS

 More than two per high power field indicates

tubular injury, and specimens should be
referred for cytologic urine testing.
 RTE IDENTIFICATION

 The rectangular, coarsely granular cells from

the PCT often resemble granular casts.
 Eccentric nucleus to be noted, though not
easily visible
 Not totally round
 CLINICAL SIGNIFICANCE

 Most clinically significant

 Presence of increased amounts is indicative
of necrosis of renal tubules with the
possibility of affecting overall renal function.
 CLINICAL SIGNIFICANCE

 Exposure to heavy metals

 Drug-induced toxicity
 Hemoglobin and myoglobin toxicity
 Viral infections (Hepatitis B)
 Pyelonephritis
 Allergic reactions
 Malignant infiltration
 Acute allogenic transplant rejection.
 OVAL FAT BODIES

 RTE cells present in the glomerular filtrate

 They appear highly refractile, and the
nucleus may be difficult to observe
 They contain lipids
 Seen in conjunction with free floating fat
droplets
 OVAL FAT BODIES

 Confirmed by using lipid stains

 Use polarizing microscopy- Maltese cross
formations in droplets containing cholesterol
 The droplets are comprised of triglycerides,
neutral fats, and cholesterol
 LIPIDURIA

 Presence of lipids in urine

 Don’t confuse starch granules and crystal
particles for fat droplets
 Lipiduria is mostly associated with nephrotic
syndrome
 Also seen with severe tubular necrosis, DM,
trauma cases that cause bone marrow
release of fat from long bones
 IN TUBULAR NECROSIS

 RTE cells containing large, non-lipid-filled

vacuoles may be seen along with normal
renal tubular cells and oval fat bodies.
 Referred to as bubble cells, they appear to
represent injured cells in which endoplasmic
reticulum has dilated prior to cell death.
 IN LIPID STORAGE DISEASES

 Large fat-laden histiocytes may also be

present.
 They are larger in size.
 LOOK AT THE NEXT SLIDE

 Oval fat bodies consist of degenerated

tubular cells containing abundant lipid, which
appears refractile.
OVAL FAT BODIES
 NEXT SLIDE

 Under polarized light, oval fat bodies

demonstrate the "Maltese cross" appearance
 INFECTIOUS AGENTS

 Bacteria
 Yeasts
 parasites
 BACTERIA

 Not normally present in urine

 Few present in case of vaginal, urethral,
external genitalia, or collection container
contamination.
 BACTERIURIA

 Presence of bacteria in urine

 Considered significant for UTI when
accompanied by WBCs
 Observation of bacteria motility is important
in order to differentiate them form amorphous
phosphates and urates.
 Can indicate either lower UTI or upper UTI –
culture important.
 COMMON BACTERIA CAUSING
UTI

 Enterobacteriaceae
 Staphylococcus
 Enterococcus
 BACTERIA

 Bacteria can be identified in unstained urine

sediments when present in sufficient
numbers. Rod-shaped bacteria and chains of
cocci are often readily identifiable.
 BACTERIA

 The images at right show E.coli bacilli from a

case of cystitis in a dog. However, small
amorphous crystals, cellular debris, and
small fat droplets can either mask or mimic
cocci.
 If there is any doubt about the presence of
bacteria, a Gram-stained smear of urine
sediment (middle panel) should be
examined.
 BACTERIA

 Although phagocytized bacteria cannot be

seen in unstained wet mounts of urine
sediment, they may found in stained smears
of sediment.
BACTERIA
BACETRIA
 YEAST

 Small
 Refractile oval structures
 May contain or may not contain bud
 In severe infection they may appear as
branched, mycelial forms.
YEAST
 YEAST CELLS

 Primarily Candida albicans seen in Diabetes

mellitus, immunocompromised patients, and
in women with vaginal moniliasis.
YEAST BACTERIA
 PARASITES

 Trichomonas vaginalis is common

 Pear-shape flagellate with an undulating
membrane
 Trichomonas is easily identified in wet
preparation and urine sediment by its rapid
darting movement
 TRICHOMONAS VAGINALIS

 When not moving, is more difficult to identify

and may resemble a WBC, transitional, or
RTE cell.
 Phase contrast microscopy is useful in
enhancing visualization of the flagella or
undulating membrane.
 Sexually transmitted
 Causes vaginal inflammation
 Urethral, and prostatic infection is
TICHOMONAS VAGINALIS
 SCHSTOSOMA HEMATOBIUM

 Bladder parasite
 Causes urinary schstosomiasis (bilharzia)
SCHSTOSMA HEMATOBIUM OVA
MCROFILARIA
 PARASITES FROM FECAL
CONTAMINATION

 Schstosoma mansoni
 Enterobius vermicularis
 Trichomonas hominis
 E.t.c.
ENTEROBIUS VERMICULARIS
 SPERMTOZOA

 Have oval, slightly tapered heads and long

flagella-like tails
 Rarely exhibit motility
 Found in urine following sexual intercourse in
both men and women, or after nocturnal
emission
 SPERMATOZOA

 Rarely of clinical significance except in cases

of infertility or retrograde ejaculation in which
semen is expelled into bladder than the
urethra
 Increase may give a false positive reagent
strip test for protein.
 May be used for legal cases, i.e. rape
 MUCUS

 Protein material produced by the glands and

epithelial cells of the genitourinary tract and
the RTE cells.
 Tam Horse-fall protein is the major
constituent
 Thread-like structures with low refractive
index on the microscope
 MUCUS

 May be confused with hyaline casts – take

care
 Mucous threads are irregular
 More frequently present in female urine
specimens
 No clinical significance
 CASTS

 Only urinary sediment s unique to the kidney

 Formed within the lumens of the DCT and
CD
 Reflect conditions of the nephrons
 Shape representative of the tubular lumen,
with parallel sides, and somewhat rounded
ends
 May contain additional elements present in
the sediment.
 CASTS

 Identified under lpf, especially along the

edges of the cover-slip
 Further identification on hpf
 COMPOSITION PO CASTS

 Casts are cylindrical structures composed

mainly of mucoprotein (the Tamm-Horse-fall
mucoprotein) which is secreted by epithelial
cells lining the loops of Henle, the distal
tubules and the collecting ducts.
 COMPOSITION OF CASTS

 The factors responsible for the precipitation

of this mucoprotein are not fully understood,
but may relate to the concentration and pH of
urine in these areas.
 COMPOSITION OF CASTS

 Casts may form in the presence or absence

of cells in the tubular lumen. If cells
(epithelial cells, WBC) are present as a cast
forms, they may adhere to, and subsequently
be surrounded by, the fibrillar protein network
 FORMATION OF CASTS

 A commonly-held theory is that cellular,

granular, and waxy casts represent different
stages of degeneration of cells in a cast.
 FROMATION OF CASTS

 The appearance of a cast observed in a

urine sediment depends largely upon the
length of time it remained in situ in the
tubules prior to being shed into the urine
 FORMATION OF CASTS

 . A cast recognizable as "cellular", for

example, was shed shortly after it was
formed. A waxy cast, in contrast, was
retained longer in the tubular system prior to
being released
 FORMATION OF CASTS

 Urine flow stasis enhances formation

 The Tam horse-fall protein is more excreted
in stress and exercise
 Presence of calcium and sodium also
enhances the formation
 TEP BY STEP FORMATION

1. Aggregation of Tam horse-fall protein into

individual protein fibrils attached to the RTE
cells
2. Interweaving of the protein fibrils to from a
loose fibrillar network (urinary sediments
may become enmeshed)
3. Further fibrillar interweaving to form a solid
structure
 STEP BY STEP FORMATION

4. Possible attachment of urinary constituents

to the solid matrix
5. Detachment of protein fibrils from the
epithelial cells
6. Excretion of the case.
Width of the cast depends on the size of the
tubule where the cast is formed
FORMATION OF CASTS
 CYLINDRURIA

 Presence cylindroids in urine

 Cylindroids are casts formed at the junction
of the ascending loop of Henle and the DCT
 The cylindroids are tapered at one end
FORMATION OF CASTS
General Interpretation of casts:

 Casts are quantified for reporting as the

number seen per low power field (10x
objective) and classified as to type (e.g.,
waxy casts, 5-10/LPF).
 Casts in urine from normal individuals are
few or none. An absence of casts does not
rule out renal disease.
General Interpretation of casts:

 Casts may be absent or very few in cases of

chronic, progressive, generalized nephritis.
 Even in cases of acute renal disease, casts
can be few or absent in a single sample
since they tend be shed intermittently.
 Furthermore, casts are unstable in urine and
are prone to dissolution with time, especially
in dilute and/or alkaline urine.
General Interpretation of casts:

 Although the presence of numerous casts is

solid evidence of generalized (usually acute)
renal disease, it is not a reliable indicator of
prognosis.
 If the underlying cause can be removed or
diminished, regeneration of renal tubular
epithelium can occur (provided the basement
membrane remains intact).
 TYPES OF CASTS

 Hyaline casts
 RBC casts
 WBC casts
 Bacterial casts
 Epithelial cell casts
 Fatty casts
 Mixed Cellular casts
 Granular casts
 Waxy casts
 Broad casts
 HYALINE CASTS

 Most frequently seen casts

 Consist almost entirely of Tam Horse-fall
protein
 Presence of 0 – 2 hyaline casts/lpf is
considered normal
 Colorless, refractive index similar to that of
urine
 Pink with Sedi stain
 MORPHOLOGY OF HYALINE
CASTS

 Varied, consisting of normal parallel sides,

and rounded ends, cylindroidal forms, and
wrinkled or convoluted shapes that indicate
aging of the cast matrix.
 HYLINE CASTS

 When present in low numbers (0-1/LPF) in

concentrated urine of otherwise normal
patients, hyaline casts are not always
indicative of clinically significant renal
disease.
HYALINE CAST
 HYALINE CASTS

 Greater numbers of hyaline casts may be

seen in association with proteinuria of renal
(e.g., glomerular disease) or extra-renal
(e.g., overflow proteinuria as in myeloma)
origin.
 In such cases it has been proposed that the
presence of excessive serum protein in the
tubular lumen promotes precipitation of the
Tamm-Horse-fall mucoprotein
 RBC CAST

 Primarily associated with damage to the

glomerulus
 However, damage to the nephron capillary
structures can also cause their formation
 Easily detected under lpf by their orange-red
color
 More fragile that other casts
 May exist as fragments or have more irregular shape
as a result of tightly packed cells adhering to the
protein matrix
 BELOW

 A red blood cell cast in which the grape-like

red cells are embedded in a hyaline matrix
perceptible only at the lower end of the cast.
From a patient with glomerulonephritis
secondary to lymphoma. x 400
 RBC CAST

 An unstained red blood cell cast, in which the

upper end of the hyaline matrix is densely
packed with RBCs. x400
 STAINED

 A similar type of red blood cell cast stained

with Sternheimer-Malbin stain. Note that both
the individual RBCs as well as the hyaline
matrix, particularly the rounded top of the
cast, is more easily perceptible than in Fig. 1.
x 400
 WBCCASTS

 Specifies infection or inflammation within the

nephron.
 Most frequently associated with
Pyelonephritis and are primary marker for
distinguishing pyelonephritis (upper UTI)
from lower UTIs.
 May also be present in nonbacterial
inflammation such as acute interstitial
nephritis, and ma y accompany RBC in
glomerulonephritis
 WBC CASTS

 Mostly comprise of neutrophils, therefore

they may appear granular, unless
disintegration has occurred the multilobed
nuclei will be present
 Differentiate from RTE casts
 Bacteria present in case of pyelonephritis
 NEXT SLIDE

 A broad white blood cell cast consisting of

polymorphonuclear leukocytes in a pink
staining hyaline matrix. White blood cell casts
are indicative of renal inflammation, either
tubulointerstitial (pyelonephritis or allergic
interstitial nephritis) or glomerular disease
(e.g. SLE nephritis) - x400 magnification.
 NEXT SLIDE

 An elongated white blood cell cast in which

the mixture of purple and blue staining WBCs
almost obscure the hyaline matrix. From the
same patient as above. x400
 BACTERIAL CASTS

 Contain bacilli
 Seen in pyelonephritis
 May resemble granular casts
 Usually accompanied with WBC casts
 Gram stain may be used for confirmation.
 EPITHELIAL CASTS

 Those containing RTE cells represent the

presence of advanced tubular destruction,
producing urinary stasis along with disruption
of the tubular linings
 Associated with heavy metal and chemical
poisoning, viral infections, and allograft
rejection
 Also accompany WBC casts in case of
pyelonephritis
 EPITHELIAL CASTS

 Use of phase contrast microscope important

to differentiate from WBC casts especially if
disintegration has occurred
 Bilirubin-stained RTE cells may be seen in
cases of hepatitis
 FATTY CASTS

 Seen in conjunction with oval fat bodies and

fat droplets in disorders causing lipiduria
 Frequently associated with nephrotic
syndrome, Diabetes mellitus, mercury
poisoning, crushing injury with disruption of
body fat
 FAT CASTS

 Fat globules, free fat or oval fat bodies inn

transparent matrix.
 Vary in size
 Highly refractive
 Can cause polarized light and Sudan black
B, Sudan III, or Oil red O fat stains for
identification
FATTY CAST
 MIXED CELLULAR CASTS

 Most frequently include RBC and WBC casts

in glomerulonephritis and WBC and RTE cell
casts, or WBC and bacterial casts in
pyelonephritis.
 Staining or phase microscopy aids in
identification
 Mostly there should also be homogenous
casts of at least one of these cell types
 EXAMPLE

 In glomerulonephritis, the predominant casts

will be the RBC casts, and in pyelonephritis,
the WBC
 GRANULAR CASTS

 Frequently seen in sediment

 May be pathologic or non-pathologic
 In non-pathologic conditions, origin of the
granules is lysosomes excreted by RTE cells
 Common in hyaline casts, and strenuous
exercises
 IN PATHOLOGY

 Disintegration of cellular casts and tubule

cells or protein aggregates filtered by the
glomerulus
 Contain an occasional recognizable cell
 Don’t mistake with artifacts such as crumps
of small crystals and fecal debris
 COARSELY GRANULAR CASTS

 Contain large granules that appear to be

degenerated cells
 Tend to be darker, shorter, and more
irregular in outline than finely granular casts
 They stain with dark purple granules in a
purple matrx
 FINELY GRANULAR CASTS

 Look much like hyaline casts

 Grayish or pale yellow in the unstained
sediment with fine dark purple granules in a
pale pink or pale purple matrix
 CLINICAL SGNIFICANCE OF
GRANULAR CASTS

 Prolonged exercise
 Renal disease
 Heavy proteinuria
 Acute and chronic renal disease
 Nephrotic syndrome
 WAXY CASTS

 Resemble hyaline casts

 Homogenous, but yellowish and more
refractive with sharper outlines
 Appears hard
 Wider than hyaline casts – broad casts
 Have irregular broken ends and fissures or
cracks in their sides
 CLINICAL SIGNIFICANCE

 Tubular obstruction with prolonged stasis,

hence called renal failure casts
 Severe chronic renal failure
 Malignant hypertension
 Acute renal disease
 Diabetes mellitus
 BROAD CASTS

 Indicate cast formation in dilated convoluted

tubules or collecting ducts
 May be of any type, usually granular or waxy
 CLINICAL SIGNIFICANCE

 Significant urinary stasis with obstruction or

disease
 Acute tubular necrosis
 Severe chronic renal disease
 End stage kidney disease
 Urinary tract obstruction
 URINARY CRYSTALS

 Unorganized urinary sediment

 Not commonly significant clinically
 CRYSTLLURIA

 Presence of crystals in urine

 Amorphous material precipitate when urine is
refrigerated, urine lose clarity and becomes
cloudy
 Important when urine is freshly voided
 Sometimes may accompany lithiasis.
 CLASSIFICATION OF URINARY
CRYSTALS

 Normal
 Abnormal
These may be found in alkaline or acidic urine
 NORMAL ACID CRYSTALS

 Amorphous urates
 Uric acid
 Acid urates
 Monosodium urate or sodium urates
 Calcium oxalate (also seen in neutral or
alkaline urine)
 NORMAL ALKALINE CRYSTALS

 Amorphous phosphates
 (Calcium oxalate)
 Triple phosphates
 Ammonium biurate
 Calcium phosphate
 Calcium carbonate
 ANORMAL CRYSTALS OF
METABLIC ORIGIN

 Cystine
 Tyrosine
 Leucine
 Cholesterol
 Bilirubin
 hemosiderine
 ABNORMAL CRYSTALS OF
IATROGENIC ORIGIN

 Sulfonamides
 Ampicillin
 Radiographic contrast media
 Acyclovir
 Indinavir sulfate
 NORMAL CRYSTALS
1. AMORPHOUS URATES

 Found in acid pH
 Chemically comprises of a sodium salt of uric
acid (sodium, potassium, magnesium, or
calcium)
 Yellowish shapeless granulation
 Birefringent
 When present in sufficient numbers they form
a characteristic fluffy pink or orange
precipitatte referred to as brick dust
 AMORPHOUS URATES

 Tend to precipitate out of highly concentrated

urine, as in dehydration and fever
 Change to uric acid when acidified with
glacial acetic acid.
 Dissolve when warmed to 60ºC and when
treated with 10% NaOH.
 URIC ACID

 Have a variety of shapes and colors

 Typically they are yellow or reddish brown
 Much chemically related to amorphous
urates
 The typical shape is whetstone, other shapes
include rhombic plates or prisms, somewhat
oval forms with pointed ends (lemon shaped)
 URIC ACID CRYSTALS

 Only pathologic when seen in fresh urine

immediately after it is voided
 Together with raised serum uric acid, may be
associated with gout or stone formation,
acute febrile conditions, chronic nephritis
 Uric acid concentration in urine depends on
dietary intake of purines and break down of
nucleic acid
 URIC ACID CRYSTALS

 Large amounts of urates or uric acid are

often seen in patients with leukemia or
lymphoma who are receiving chemotherapy
 Strongly birefringent
 Soluble when heated at 60ºC and when
treated with 10% NaOH
URIC ACID CRYSTAL
 URIC ACID CRYSTAL –
POLARIZING MICROSCOPY
 ACID URATES

 Rare forms uric acid

 Seen in acidic or neutral pH
 They may be sodium, potassium, or
ammonium urates and are seen as brown
spheres or clusters that resemble ammonium
biurate
 Seen together with amorphous urates
 Same significance as amorphous urates
MONOSODIUM URATE OR
SODIUM URATES

 Another rare form of uric acid

 Monosodium urate is the form of uric acid
seen in the synovial fluid of patients with
gout.
 If present in urine, it appears as tiny, slender,
colorless needles
 CALCIUM OXALATE

 Envelope shaped
 Octahedrons that vary somewhat in size but
are typically small, colorless and glistering
 Occasionally seen as rectangular forms of
pyramidal ends
 Polarize light
 CALCIUM OXALATE

 Common in acidic urine

 May also be seen in neutral or alkaline urine
 Little clinical significance
 May be present in association with stone
formation, as calcium oxalate is the common
constituent in kidney stones.
 CALCIUM OXALATE

 Correlation between calcium stones and

excess oxalate and uric acid in the urine.
 Excess oxalate may result from ingestion of
food stuffs containing oxalic acid, such as
spinach and rhubarb, and from ingestion of
vitamin C, because oxalic acid is a
breakdown product of ascorbic acid
 CALCIUM OXALATE CRYSTALS

 May also be seen in cases of ethylene glycol

or methoxyfluran poisoning.
 Calcium Oxalate Dihydrate

 Calcium oxalate dihydrate crystals typically

are seen as colorless squares whose corners
are connected by intersecting lines
(resembling an envelope). They can occur in
urine of any pH
CALCIUM OXALATE DIHYDRATE

 Most common form

 Colorless
 Octahedral envelope or as two pyramids
joined together
CALCIUM OXALATE DIHYDRATE
 CALCIUM OXALATE
MONOHYDRATE

 Less characteristic
 Less frequently seen
 Oval or dumbbell shaped
 Both the monohydrate and the dihyrate forms
are birefringent
 CALCIUM OXALATE
MONOHYRATE

 Calcium oxalate monohydrate crystals vary

in size and may have a spindle, oval, or
dumbbell shape.
 Most commonly, they appear as flat,
elongated, six-sided crystals ("fence pickets")
such as shown to the right.
 The arrow in the photo indicates a
"daughter" crystal forming on the face of a
larger underlying crystal.
CALCIUM OXALATE
MONOHYDRATE
NORMAL ALKALINE CRYASTALS
1. AMORPHOUS PHOSPHATES

 Give a finer or lacy precipitate than the

amorphous urates, and are colorless
 Most common cause of turbidity in alkaline
urine
 Seen as white precipitate microscopically
 They do not dissolve when heated but
soluble in in acetic acid and dilute in HCl
 ARMOPHOUS PHOSPHATES

 Appear like, and are often seen with,

bacteria; care must be taken not to overlook
bacteria when they are present.
 Use of phase contrast is very useful
 TRIPPLE PHOSPHATES

 (ammonium magnesium)
 Also called struvite
 Colorless
 Commonly show great variation in size
 Characteristic coffin lid
 May also be seen as large long prisms that
are difficult to distinguish from calcium
phosphate
 CLINICAL SIGNIFICANCE

 Renal calculi
 Chronic pyelitis
 Enlarged prostate
 UTI
TRIPPLE PHOSPHATES
 AMMONIUM BIURATE

 Ammonium salt
 Alkaline counterpart of uric acid and
amorphous urates in urine
 Spherical with radial or concentric striations
and long prismatic spicules, resembling thorn
apples
 AMMONIUM BIURATE

 Yellow
 May be mistaken for some forms of
sulfonamide drugs that may precipitate out of
urine
 Often present in alkaline urine
 Soluble at 60ºC with acetic acid and in strong
alkali
AMMONIUM BIURATE
 CALCIUM PHOSPHATE

 Colorless crystals
 Occasionally seen in alkaline normal urine
 Appear as slender prisms with wedge-like
end occurring in singly or arranged in
rosettes
 May appear like triple phosphate crystals as
long as prisms of calcium monohydrate, also
known as brusite
 CALCIUM PHOSPHATE

 Insoluble when heated to 60ºC

 Slightly soluble in dilute acetic acid
 Soluble in dilute hydrochloric acid
 Associated with renal calculi
 Can be found in normal urine
 CALCIUM CARBONATE

 Tiny, colorless granules that typically occur in

pairs (dumbbells),
 So small
 Soluble in acetic acid with effervescence
 No clinical significance
CALCIUM CARBONATE
CRYSTALS
 ABNORMAL CRYSTALS

 Seen in urine specimens with pH 6.5 or less

 Reported as numbers seen per high power
field
 ABNORMAL CRYSTALS OF
METABOLIC ORIGIN

 Due to poor metabolism of some amino acids

 May be cholesterol crystals
 Bilirubin, and hemosiderine
 CYSTINE CRYSTALS

 Colorless, refractile, hexagonal plates that

are often laminated
 Seen in cystinuria –hereditary condition
 There is transport disorder of amino acids,
cystine, ornithine, lysine, and arginine
(COLA)
 Only cystine crystalizes
 CYSTINE CRYSTALS

 Confirmed by cyanide-nitroprusside reaction

 Cystine is reduced to cystein by sodium
cyanide, three free sulfohydril groups that
result react with nitroprusside to give a red
purple color
 Remain insoluble up to pH 7.4
 Soluble in alkali (especially ammonia) and
dilute HCl
 Soluble in boiling water, acetic acid, alcohol, and
ether.
CYSTINE
CYSTINE CRYSTALS
 TYROSINE

 Rare
 May be present as a result of inherited amino
acid disorders (hereditary tyrosinosis and
oasthouse disease), and together with
Leucine, in patients with massive liver failure
 Colorless fine silky needles arranged in
sheaves or clumps, which appear black as
the microscope is foccused
 TYROSINE

 Soluble in alkali and dilute mineral acid

 Relatively soluble when heated
 Insoluble in alcohol and ether
TYROSINE
 LEUCINE

 Yellow, oily looking spheres with radial and

concentric striations
 Of metabolic origin and extremely rare
 Appear together with tyrosine
 Associated with severe liver disease
LEUCINE
 CHOLESTEROL

 Rarely seen unless specimens have been

refrigerated because the lipids remain in
droplet form
 Resemble a rectangular plate with a notch in
one or more corners
 Associated with disorders producing lipiduria,
such as the nephrotic syndrome, and are
seen in conjunction with fatty casts, and oval
fat bodies
 BILIRUBIN

 Occasionally seen in patients with bilirunuria

 Chemical confirmation be done
 Seen as reddish brown needles that cluster
in clumps, or as spheres.
BILIRUBIN
 HEMOSIDERINE

 Seen in acid or alkaline urines

 Seen after sever intravascular hemolysis
episode
 Coarse, yellow-brown granules, they may be
seen as free or contained in RTE cells
 Confirmed with Rous test
HEMOSIDERINE
 ABNORMAL CRYSTALS OF
IATROGENIC ORIGIN

 Sulfonamide crystals
 Ampicillin
 Acrovir
 Indinavir
INDINAVIR CRYSTALS