CABAHIT, KRISTENE DIANE A. BSMLS 3-A SEPT.

28, 2020

SUMMARY REPORT OF MICROSCOPIC EXAMINATION

 Macroscopic Screening also referred to as Chemical Seiving
 This is used in order to determine the abnormalities in the physical and chemical
portions of the urinalysis that plays a vital role in the decision to perform a
microscopic analysis.
 There are certain parameters that can be considered significant vary among laboratories and
these are:
 Color
 Clarity
 Blood
 Protein
 Nitrite
 Leukocyte esterase
 Glucose
 The Clinical and Laboratory Standards Institute (CLSI) recommends that microscopic
examination be performed when requested by a physician, when a laboratory specified patient
population is being tested, or when any abnormal physical or chemical result is obtained.

Preparation and Examination of the Urine Sediment

 Microscopic analysis is subject to several procedural variations

 The first procedure to standardize the quantitation of formed elements in the urine microscopic
analysis was developed by Addis in 1926.
 The Addis count, as it is called, used a hemocytometer to count the number of RBCs, WBCs,
casts, and epithelial cells present in a 12-hour specimen
 Normal values have a wide range and are approximately 0 to 500,000 RBCs, 0 to 1,800,000
WBCs and epithelial cells, and 0 to 5000 hyaline casts
 Addis count, which was used primarily to monitor the course of diagnosed cases of renal disease

Commercial Systems

 Conventional method of placing a drop of centrifuged urine on a glass slide, adding a cover
slip, and examining microscopically has been substantially improved through the use of
commercial slide systems.
 The CLSI recommends their use together with standardization of all phases of the
methodology.

Specimen Preparation

 Specimens should be examined while fresh or adequately preserved.

 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
nonpathologic crystals that can obscure other elements in the urine sediment.
 Midstream clean-catch specimen minimizes external contamination of the sediment.

Specimen Volume

 A standard amount of urine, usually between 10 and 15 mL, is centrifuged in a conical tube.
 12-mL volume is frequently used because multiparameter reagent strips are easily immersed in
this volume.
 Some laboratories choose to make this correction prior to reporting. For example, if 6 mL of
urine is centrifuged, the results are multiplied by 2.

Centrifugation

 The speed of the centrifuge and the length of time the specimen is centrifuged should be
consistent.
 The speed of the centrifuge and the length of time the specimen is centrifuged should be
consistent.
 Centrifugation calibration should be routinely performed in the laboratory.
 To prevent biohazardous aerosols, all specimens must be centrifuged in capped tubes.

Sediment Preparation

 Volumes of 0.5 and 1.0 mL are frequently used in doing sediment preparation.
 The volume of urine centrifuged divided by the sediment volume equals the concentration
factor, which in the preceding examples is 24 and 12
 The probability of detecting elements present in low quantities and is used when quantitating
the number of elements present per millilitre.
 The pipettes are also used for sediment resuspension and transfer of specimens to the slide.
 The sediment must be thoroughly resuspended by gentle agitation.
 Thorough resuspension is essential to provide equal distribution of elements in the microscopic
examination fields.

Volume of Sediment Examined

 The volume of sediment placed on the microscope slide should be consistent for each specimen.
 The recommended volume is 20 L (0.02 mL) covered by a 22 22 mm glass cover slip.
 Commercial systems control the volume of sediment examined by providing slides with
chambers capable of containing a specified volume.

Examination of the Sediment

 Performed should be consistent and should include observation of a minimum of 10 fields under
both low (10) and high (40) power.
 If the conventional glass-slide method is being used, casts have a tendency to locate near the
edges of the cover slip;
 It is essential that sediments be examined under reduced light when using bright-field
microscopy.
  An epithelial cell will be present to provide a point of reference.
 Continuous focusing with the fine adjustment aids in obtaining a complete representation of the
sediment constituents.

Reporting the Microscopic Examination

 Casts are reported as the average number per low-power field following examination of 10
fields, and RBCs and WBCs, as the average number per 10 high-power fields.
 Epithelial cells, crystals, and other elements are frequently reported in semiquantitative terms
such as, rare, few, moderate, and many, or as 1±, 2±, 3±, and 4±.
 Laboratories should evaluate the advantages and disadvantages of adding an additional
calculation step to the microscopic examination.

Correlation of Results

 Many factors can influence the appearance of the urinary sediment, including cells and casts in
various stages of development;
 Degeneration, distortion of cells and crystals by the chemical content of the specimen;
 The presence of inclusions in cells and casts, and contamination by artifacts

Sediment Stains

 Elements such as hyaline casts have a refractive index very similar to that of urine.
 Imparts identifying characteristics to cellular structures, such as the nuclei, cytoplasm, and
inclusions.
 Most frequently used stain in urinalysis is the Sternheimer-Malbin stain, which consists of crystal
violet and safranin O.
 The dye is absorbed well by WBCs, epithelial cells, and casts, providing clearer delineation of
structure and contrasting colors of the nucleus and cytoplasm.
 A 0.5% solution of toluidine blue, a metachromatic stain, provides enhancement of nuclear
detail.
 Useful in the differentiation between WBCs and renal tubular epithelial cells and is also used in
the examination of cells from other body fluids.

Lipid Stains

 The lipid stains, Oil Red O and Sudan III, and polarizing microscopy can be used to confirm the
presence of these elements.
 Generally, cholesterol does not stain but is capable of polarization.

Gram Stain

 Gram stain is used primarily in the microbiology section for the differentiation between gram-
positive (blue) and gram negative (red) bacteria.
 To perform Gram staining, a dried, heat-fixed preparation of the urine sediment must be used.

Hansel Stain
  A drug-induced allergic reaction producing inflammation of the renal interstitium, eosinophils
are present in the sediment.
 Preferred stain for urinary eosinophils is Hansel stain, consisting of methylene blue and eosin Y
(Lide Labs, Inc, Florissant, Mo.); however, Wright’s stain can also be used.

Prussian Blue Stain

 Yellow-brown granules may be seen in renal tubular epithelial cells and casts or free-floating in
the urine sediment.
 It is used and stains the hemosiderin granules a blue color.

Cytodiagnostic Urine Testing

 The preparation of permanent slides using cytocentrifugation followed by staining with

Papanicolaou stain provides an additional method for detecting and monitoring renal disease.
 Cytodiagnostic urine testing also provides more definitive information about renal tubular
changes associated with transplant rejection; viral.
 The urinalysis laboratory should refer specimens with unusual cellular findings to the cytology
laboratory for further examination.

Microscopy

 Microscopic examination of urine is best performed when the laboratorian is knowledgeable

about the types of microscopes available, their primary characteristics, and the proper use and
maintenance of these microscopes.
 Bright-field microscopy is the most common type of microscopy performed in the urinalysis
laboratory.

Microscope

 Essentially all types of microscopes contain a lens system, illumination system, and a body
consisting of a base, body tube, and nosepiece.
 Primary components of the lens system are the oculars, the objectives, and the coarse- and
fineadjustment knobs.
 Illumination system contains the light source, condenser, and field and iris diaphragms.
 The compound bright-field microscope is used primarily in the urinalysis laboratory and consists
of a two-lens system combined with a light source.
 Second lens system, the ocular lens, is located in the eyepiece. The path of light passes through
the specimen up to the eyepiece.
 Laboratory microscopes normally contain oculars capable of increasing the magnification 10
times; the field of view is determined by the eyepiece and is the diameter of the lens.
 Objectives are adjusted to be near the specimen and perform the initial magnification of the
object on the mechanical stage. The image then passes to the oculars for further resolution.

Kohler Illumination
  Two adjustments to the condenser—centering and Köhler illumination—provide optimal
viewing of the illuminated field. They should be performed whenever an objective is changed to
center the condenser and obtain Köhler illumination.
 Additional focusing of the object should be performed using the adjustment knobs and the
rheostat on the light source.
 Routine preventive maintenance procedures on the microscope ensure good optical
performance.
 An annual professional cleaning for the microscope is recommended. Light sources are replaced
as necessary .

Types of Microscopy

 Bright-Field Microscopy
 Phase-Contrast Microscopy
 Polarizing Microscopy
 Interference-Contrast Microscopy
 Dark-Field Microscopy
 Fluorescence Microscopy

Sediment Constituents

 The normal urine sediment may contain a variety of formed elements.

 They must learn to trust their observations after looking at the recommended number of fields.
 Commonly listed values include zero to two or three RBCs per hpf, zero to five to eight WBCs per
hpf.

Red Blood Cell

 Appear as smooth, non-nucleated, biconcave disks measuring approximately 7 mm in diameter.

 Must be identified using high-power (40) objective (400x).
 Routinely reported as the average number seen in 10 hpfs.
 Concentrated (hypersthenuric) urine, the cells shrink due to loss of water and may appear
crenated or irregularly shaped.
 These large empty cells are called ghost cells and can be easily missed if specimens are not
examined under reduced ligh.
 The most difficult for students to recognize.
 Lack of characteristic structures, variations in size and close resemblance to other sediment
constituents.
 Yeast cells usually exhibit budding (Fig. 6-10). Oil droplets and air bubbles are highly refractile.
 The rough appearance of crenated RBCs may resemble the granules seen in WBCs.
 Adding acetic acid to a portion of the sediment will lyse the RBCs, leaving the yeast, oil droplets,
and WBCs intact.
 Morphology of urinary RBCs as an aid in determining the site of renal bleeding.
 RBCs that vary in size, have cellular protrusions, or are fragmented are termed dysmorphic and
have been associated primarily with glomerular bleeding.

Clinical Significance
  Presence of RBCs in the urine is associated with damage to the glomerular membrane or
vascular injury within the genitourinary tract.
 Microscopic analysis may be reported in terms of greater than 100 per hpf or as specified by
laboratory protocol.
 Macroscopic hematuria is frequently associated with advanced glomerular damage.
 Damage to the vascular integrity of the uri nary tract caused by trauma, acute infection or
inflammation, and coagulation disorders.
 The observation of microscopic hematuria can be critical to the early diagnosis of glomerular
disorders and malignancy of the urinary tract and to confirm the presence of renal calculi.

White Blood Cells

 WBCs are larger than RBCs, measuring an average of about 12 mm in diameter.

 The predominant WBC found in the urine sediment is the neutrophil.
 Neutrophils are much easier to identify than RBCs because they contain granules and multilobed
nuclei.
 They are still identified using high power microscopy and are also reported as the average
number seen in 10 hpfs.
 Neutrophils lyse rapidly in dilute alkaline urine and begin to lose nuclear detail.
 Brownian movement of the granules within these larger cells produces a sparkling appearance.
 The presence of urinary eosinophils is primarily associated with drug-induced interstitial
nephritis.
 Small numbers of eosinophils may be seen with urinary tract infection (UTI) and renal transplant
rejection.
 The percentage of eosinophils in 100 to 500 cells is determined.
 Eosinophils are not normally seen in the urine.
 Lymphocytes are the smallest WBCs, they may resemble RBCs.
 Monocytes, macrophages, and histiocytes are large cells and may appear vacuolated or contain
inclusions.
 Primary concern in the identification of WBCs is the differentiation of mononuclear cells and
disintegrating neutrophils from renal tubular epithelial (RTE) cells.
 Supravital staining or the addition of acetic acid can be used to enhance nuclear detail (Fig. 6-
18), if necessary; higher numbers may be present in urine from females.

Epithelial Cells

 It is not unusual to find epithelial cells in the urine, because they are derived from the linings of
the genitourinary system.
 Three types of epithelial cells are seen in urine: squamous, transitional, and renal tubular.
 Squamous cells are the largest cells found in the urine sediment.
 They contain abundant, irregular cytoplasm and a prominent nucleus about the size of an RBC.
 The first structures observed when the sediment is examined under low-power magnification.
 It serves as a good reference for focusing of the microscope.
 Squamous epithelial cells are commonly reported in terms of rare, few, moderate, or many.
 Difficulty identifying squamous cells is rare.
  They represent normal cellular sloughing and have no pathologic significance.
 Specimens collected using the midstream clean-catch technique contain less squamous cell
contamination.
 Variation of the squamous epithelial cell is the clue cell, which does have pathologic significance.
 Clue cells are indicative of vaginal infection by the bacterium Gardnerella vaginalis.; this gives
the cell a granular, irregular appearance.
 Clue cells is performed by examining a vaginal wet preparation for the presence of the
characteristic cells.
 Transitional epithelial cells are smaller than squamous cells and appear in several forms,
including spherical, polyhedral, and caudate.
 It is caused by the ability of transitional epithelial cells to absorb large amounts of water.
 All forms have distinct, centrally located nuclei.
 Usually reported as rare, few, moderate, or many following laboratory protocol.
 Presence of a centrally located rather than eccentrically placed nucleus, and supravital staining,
can aid in the differentiation.
 Transitional epithelial cells originate from the lining of the renal pelvis, calyces, ureters, and
bladder, and from the upper portion of the male urethra.
 Increased numbers of transitional cells seen singly, in pairs, or in clumps (syncytia).
 The increase in transitional cells exhibiting abnormal morphology such as vacuoles and irregular
nuclei may be indicative of malignancy or viral infection.
 Renal tubular epithelial (RTE) cells vary in size and shape depending on the area of the renal
tubules from which they originate.
 The cells from the proximal convoluted tubule (PCT) are larger than other RTE cells. They tend to
have a rectangular shape and are referred to as columnar or convoluted cells.
 This is a PCT cell that has absorbed fat globules and could easily be mistaken for a granular or
fatty cast.
 Cells from the distal convoluted tubule (DCT) are smaller than those from the PCT and are round
or oval.
 Observation of the eccentrically placed round nucleus aids in differentiating them from spherical
transitional cells.
 Collecting duct RTE cells are cuboidal and are never round.
 RTE cells are often present as a result of tissue destruction (necrosis), the nucleus is not easily
visible in unstained sediment.
 RTE cells must be identified and enumerated using high power magnification.
 They may be reported as rare, few, moderate, or many, or as the actual number per high-power
field.

Clinical Significance

 RTE cells are the most clinically significant of the epithelial cells. The presence of increased
amounts is indicative of necrosis of the renal tubules, with the possibility of affecting overall
renal function.
 Conditions producing tubular necrosis include exposure to heavy metals, drug-induced
toxicity, hemoglobin and myoglobin toxicity, viral infections (hepatitis B), pyelonephritis,
 allergic reactions, malignant infiltrations, salicylate poisoning, and acute allogenic transplant
rejection.
 Renal fragments are an indication of severe tubular injury with basement membrane
disruption.
 Single cuboidal cells are particularly noticeable in cases of salicylate poisoning.
 One of the functions of RTE cells is reabsorption of the glomerular filtrate, it is not unusual
for them to contain substances from the filtrate.
 RTE cells absorb bilirubin present in the filtrate as the result of liver damage.
 Confirmation of the presence of hemosiderin is performed by staining the sediment with
Prussian blue. The iron-containing hemosiderin granules stain blue.

Oval Fat Bodies

 RTE cells absorb lipids that are present in the glomerular filtrate.
 They then appear highly refractile, and the nucleus may be more difficult to observe.
 Confirmed by staining the sediment with Sudan III or Oil Red O fat stains and examining the
sediment using polarized microscopy.
 Maltese cross formations in droplets containing cholesterol.
 Staining should be performed on sediments negative under polarized light. Oval fat bodies are
reported as the average number per hpf .
 Free-floating fat droplets also stain or polarize depending on their composition.
 Lipiduria is most frequently associated with damage to the glomerulus caused by the nephrotic
syndrome.
 It is also eferred to as “bubble cells,” they appear to represent injured cells in which the
endoplasmic reticulum has dilated prior to cell death.

Bacteria

 Bacteria are not normally present in urine. However, unless specimens are collected under
sterile conditions.
 May produce a positive nitrite test result and also frequently result in a pH above 8,
indicating an unacceptable specimen.
 They are present in the form of cocci (spherical) or bacilli (rods).
 It is reported as few, moderate, or many per high-power field.
 Observing bacteria for motility also is useful in differentiating them from similarly appearing
amorphous phosphates and urates.
 The presence of bacteria can be indicative of either lower or upper urinary tract infection.
 Most frequently associated with UTI are the Enterobacteriaceae referred as gram-negative
rods.
 The actual bacteria producing an UTI cannot be identified with the microscopic examination.

Yeast

 Yeast cells appear in the urine as small, refractile oval structures that may or may not contain a
bud.
 It is usually reported as rare, few, moderate, or many per hpf.
  Differentiation between yeast cells and RBCs can sometimes be difficult.
 The acidic, glucose-containing urine of patients with diabetes provides an ideal medium for the
growth of yeast.
 A true yeast infection should be accompanied by the presence of WBCs.

Parasites

 The most frequent parasite encountered in the urine is Trichomonas vaginalis.

 Trichomonas trophozoite is a pearshaped flagellate with an undulating membrane.
 Usually reported as rare, few, moderate, or many per hpf.
 T. vaginalis is a sexually transmitted pathogen associated primarily with vaginal inflammation.
Infection of the male urethra and prostate is asymptomatic.
 The ova of the bladder parasite Schistosoma haematobium will appear in the urine.
 Fecal contamination of a urine specimen can also result in the presence of ova from intestinal
parasites in the urine sediment.

Spermatozoa

 Spermatozoa are easily identified in the urine sediment by their oval, slightly tapered heads and
long, flagella-like tails.
 Urine is toxic to spermatozoa they rarely exhibit the motility observed when examining a semen
specimen.
 Occasionally found in the urine of both men and women following sexual intercourse,
masturbation, or nocturnal emission.
 A positive reagent strip test for protein may be seen when increased amounts of semen are
present.
 Laboratories supporting the reporting of spermatozoa cite the possible clinical significance and
the minimal possibility of legal consequences.

Mucus

 It is a protein material produced by the glands and epithelial cells of the lower genitourinary
tract and the RTE cells; Tamm-Horsfall protein is a major constituent of mucus
 Appears microscopically as thread-like structures with a low refractive index.
 Usually be made by observing the irregular appearance of the mucous threads.
 It is reported as rare, few, moderate, or many per lpf.

Casts

 Casts are the only elements found in the urinary sediment that are unique to the kidney.
 Formed within the lumens of the distal convoluted tubules and collecting ducts.
 It provides a microscopic view of conditions within the nephron.
 Examination of the sediment for the detection of casts is performed using lower power
magnification.
 Once detected, casts must be further identified as to composition using high-power
magnification.
 It is reported as the average number per 10 lpfs
Cast Composition and Formation

 Major constituent of casts is Tamm-Horsfall protein, a glycoprotein excreted by the RTE cells of
the distal convoluted tubules and upper collecting ducts; proteins present in the urinary filtrate.
 Tamm-Horsfall protein is found in both normal and abnormal urine and, as discussed previously,
is a major constituent of mucus. It is not detected by reagent strip protein methods.
 As the cast forms, urinary flow within the tubule decreases as the lumen becomes blocked.
 Formation of casts at the junction of the ascending loop of Henle and the distal convoluted
tubule may produce structures with a tapered end.
 Cylindruria is the presence of urinary casts.
 The types of casts found in the sediment represent different clinical conditions and will be
discussed separately in this section.

Hyaline Casts

 Most frequently seen cast is the hyaline type, which consists almost entirely of Tamm-Horsfall
protein.
 The Qon-exis of zero to two hyaline casts per lpf is considered normal.
 Hyaline casts appear colorless in unstained sediments and have a refractive index similar to that
of urine.
 They can easily be overlooked if specimens are not examined under subdued light.
 Morphology of hyaline casts is varied, consisting of normal parallel sides and rounded ends,
cylindroid forms, and wrinkled or convoluted shapes that indicate aging of the cast matrix.

RBC Casts

 The presence of RBC casts is much more specific, showing bleeding within the nephron
 RBC casts are primarily associated with damage to the glomerulus (glomerulonephritis) that
allows passage of the cells through the glomerular membrane.
 Easily detected under low power by their orange-red color.
 More fragile than other casts and may exist as fragments or have a more irregular shape as the
result of tightly packed cells adhering to the protein matrix.
 The actual presence of RBCs must also be verified to prevent the inaccurate reporting of Qon-
existent RBC casts.
 It is highly improbable that RBC casts will be present in the absence of free-standing RBCs and a
positive reagent strip test for blood.
 Presence of massive hemoglobinuria or myoglobinuria, homogenous orange-red or red-brown
casts may be observed.
 They are associated with the acute tubular necrosis often caused by the toxic effects of massive
hemoglobinuria that can lead to renal failure.

WBC Casts
  The appearance of WBC casts in the urine signifies infection or inflammation within the
nephron.
 They are visible under low-power magnification but must be positively identified using high
power.
 Supravital staining may be necessary to demonstrate the characteristic nuclei.
 Casts tightly packed with WBCs may have irregular borders.
 WBCs frequently form clumps, and these do not have the same significance as casts.

Bacterial Casts

 Containing bacilli both within and bound to the protein matrix are seen in pyelonephritis.
 It can be difficult, because packed casts packed with bacteria can resemble granular casts.
 Confirmation of bacterial casts is best made by performing a Gram stain on the dried or
cytocentrifuged sediment.

Epithelial Cell Casts

 Casts containing RTE cells represent the presence of advanced tubular destruction, producing
urinary stasis along with disruption of the tubular linings.
 They are associated with heavy metal and chemical or drug-induced toxicity, viral infections, and
allograft rejection.
 Owing to the formation of casts in the distal convoluted tubule, the cells visible on the cast
matrix are the smaller, round, and oval cells.
 Staining and the use of phase microscopy can be helpful to enhance the nuclear detail needed
for identification.

Fatty Casts

 Fatty casts are seen in conjunction with oval fat bodies and free fat droplets in disorders causing
lipiduria.
 They are highly refractile under bright-field microscopy.
 Confirmation of fatty casts is performed using polarized microscopy and Sudan III or Oil Red O
fat stains.
 Fats do not stain with Sternheimer-Malbin stain.

Mixed Cellular Casts

 Most frequently encountered include RBC and WBC casts in glomerulonephritis and WBC and
RTE cell casts, or WBC and bacterial casts in pyelonephritis.
 Presence of mixed elements in a cast may make identification more difficult.
 Bacteria are often incorporated into WBC casts and provide little additional diagnostic
significance.

Granular Casts

 Coarsely and finely granular casts are frequently seen in the urinary sediment and may be of
pathologic or nonpathologic significance.
  It is not considered necessary to distinguish between coarsely and finely granular casts.
 The origin of the granules in nonpathologic conditions appears to be from the lysosomes
excreted by RTE cells during normal metabolism.
 Scanning electron microscope studies have confirmed that granular casts seen in
conjunction with WBC casts contain WBC granules of varying sizes.
 Occurring as a result of cellular disintegration may contain an occasional recognizable cell.
 Easily visualized under low-power microscopy; final identification should be performed using
high power to determine the presence of a cast matrix.

Waxy Casts

 They are representative of extreme urine stasis, indicating chronic renal failure.
 Usually seen in conjunction with other types of casts associated with the condition that has
caused the renal failure.
 It is more easily in visualizing than hyaline casts because of their higher refractive index.
 With supravital stains, waxy casts stain a homogenous, dark pink.

Broad Casts

 Also referred to as renal failure casts, broad casts like waxy casts represent extreme urine
stasis.
 Bile-stained broad, waxy casts are seen as the result of the tubular necrosis caused by viral
hepatitis.

Urinary Crystals

 Crystals frequently found in the urine are rarely of clinical significance.

 Detects the presence of the relatively few abnormal types that may represent such disorders as
liver disease, inborn errors of metabolism, or renal damage caused by crystallization of
iatrogenic compounds within the tubules.
 It usually reported as rare, few, moderate, or many per hpf.

Crystal Formation

 They are formed by the precipitation of urine solutes, including inorganic salts, organic
compounds, and medications.
 Precipitation is subject to changes in temperature, solute concentration, and pH, which affect
solubility.
 Extremely abundant in refrigerated specimens and often present problems because they
obscure clinically significant sediment constituents.
 A valuable aid in the identification of crystals is the pH of the specimen because this determines
the type of chemicals precipitated.

General Identification Techniques

  Crystals are routinely classified not only as normal and abnormal, but also as to their
appearance in acidic or alkaline urine.
 Changes in temperature and pH contribute to crystal formation, reversal of these changes can
cause crystals to dissolve.
 Amorphous urates that frequently form in refrigerated specimens and obscure sediments may
dissolve if the specimen is warmed.
 Amorphous phosphates require acetic acid to dissolve, and this is not practical, as formed
elements, such as RBCs, will also be destroyed.
 When solubility characteristics are needed for identification, the sediment should be aliquoted
to prevent destruction of other elements.

Normal Crystals Seen in Acidic Urine

 The most common crystals seen in acidic urine are urates, consisting of amorphous urates, uric
acid, acid urates, and sodium urates.
 Amorphous urates appear microscopically as yellowbrown granules; occur in clumps resembling
granular casts.
 Uric acid crystals are seen in a variety of shapes, including rhombic, four-sided flat plates
(whetstones), wedges, and rosettes; usually appear yellow-brown, but may be colorless and
have a six-sided shape.
 Acid urates and sodium urates are rarely encountered and, like amorphous urates, are seen in
less acidic urine; Acid urate crystals appear as larger granules and may have spicules similar to
the ammonium biurate crystals seen in alkaline urine; Sodium urate crystals are needle-shaped
and are seen in synovial fluid during episodes of gout, but do appear in the urine.
 Calcium oxalate crystals are frequently seen in acidic urine, but they can be found in neutral
urine and even rarely in alkaline urine; most common form of calcium oxalate crystals is the
dihydrate that is easily recognized as a colorless, octahedral envelope or as two pyramids joined
at their bases.
 Calcium phosphate crystals are not frequently encountered. They may appear as colorless, flat
rectangular plates or thin prisms often in rosette formations.

Normal Crystals Seen in Alkaline Urine

 Amorphous phosphates are granular in appearance, similar to amorphous urates; they can be
differentiated from amorphous urates by the color of the sediment and the urine pH.
 Triple phosphate crystals are commonly seen in alkaline urine; they are easily identified by their
prism shape that frequently resembles a “coffin lid”.
 Calcium carbonate crystals are small and colorless, with dumbbell or spherical shapes; they may
occur in clumps that resemble amorphous material, but they can be distinguished by the
formation of gas after the addition of acetic acid.
 Ammonium biurate crystals exhibit the characteristic yellow-brown color of the urate crystals
seen in acidic urine; they are frequently described as “thorny apples” because of their
appearance as spicule-covered spheres.

Abnormal Urine Crystals

  Most abnormal crystals have very characteristic shapes; iatrogenic crystals can be caused by
a variety of compounds, particularly when they are administered in high concentrations.
 Cystine crystals are found in the urine of persons who inherit a metabolic disorder that
prevents reabsorption of cystine by the renal tubules (cystinuria); appear as colorless,
hexagonal plates and may be thick or thin.
 Cholesterol crystals are rarely seen unless specimens have been refrigerated, because the
lipids remain in droplet form; most characteristic appearance, resembling a rectangular
plate with a notch in one or more corners.
 Crystals of radiographic contrast media have a very similar appearance to cholesterol
crystals and also are highly birefringent; differentiation is best made by comparison of the
other urinalysis results and the patient history.
 Tyrosine crystals appear as fine colorless to yellow needles that frequently form clumps or
rosettes; may also be encountered in inherited disorders of amino-acid metabolism.
 Leucine crystals are yellow-brown spheres that demonstrate concentric circles and radial
striations; seen less frequently than tyrosine crystals.
 Bilirubin crystals are 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.
 Sulfonamide crystals, finding of these crystals in the urine of patients being treated for UTIs
was common; shapes most frequently encountered include needles, rhombics, whetstones,
sheaves of wheat, and rosettes with colors ranging from colorless to yellow-brown.
 Ampicillin crystals appear as colorless needles that tend to form bundles following
refrigeration; knowledge of the patient’s history can aid in the identification.

Urinary Sediment Artifacts

 Artifacts frequently resemble pathologic elements such as RBCs and casts, artifacts can present
a major problem to students.
 Mostly, very highly refractile or occur in a different microscopic plane than the true sediment
constituents.
 Starch granule contamination may occur when cornstarch is the powder used in powdered
gloves; resemble fat droplets when polarized, producing a Maltese cross formation; occasionally
be confused with RBCs.
 Oil droplets and air bubbles also are highly refractile and may resemble RBCs to inexperienced
laboratory personnel; presence of these artifacts should be considered in the context of the
other urinalysis results.
 Pollen grains are seasonal contaminants that appear as spheres with a cell wall and occasional
concentric circles; large size may cause them to be out of focus with true sediment constituents.
 Hair and fibers from clothing and diapers may initially be mistaken for casts; they are usually
much longer and more refractile.
 Fibers often polarize, whereas, casts, other than fatty casts, do not.
 Fecal artifacts may appear as plant and meat fibers or as brown amorphous material in a variety
of sizes and shapes.