LE5 AUBF

SY 2021-2022
1st SEMESTER
BS-MLS
PROF. ETHEL MARIE MANGADA, RMT

MICROSCOPIC EXAMINATION OF URINE

OUTLINE
I Microscopic Examination of Urine
II Sediment Constinuents
A Red Blood Cells
B White Blood Cells
C Epithelial Cells
D Squamous Epithelial Cells
E Clue Cells
F Transitional (Urothelial) Cells
G RTE Cells
H PCT Cells
I DCT Cells
J Collecting Duct Rte
K Oval Fat Bodies
L Bacteria
M Yeast
N Parasites
O Spermatozoa

MICROSCOPIC EXAMINATION OF URINE

 Purpose: To detect and to identify insoluble materials
present in the urine.
o Insoluble materials can be the materials coming
from our blood circulation.
 Some laboratories do not necessarily perform
microscopic exam, they just perform the microscopic
exam when the physical and chemical examination
suggest or recommend.
o Example: In physical examination of urine, when
the color of the urine is red, it gives us the hint
that microscopically, we can see presence of
intact RBCs.  WBC (arrowheads) are larger, colorless and more
granular than the redder smaller RBC (arrows), which
INTRODUCTION have no internal texture (although appear slightly
biconcave).
IDENTIFICATION OF INSOLUBLE SUBSTANCES
(FORMED ELEMENTS)
 Red blood cells (RBCs)
 White blood cells (WBCs)
 Both can be seen or readily observe in the
urine especially when we undergo strenuous
exercises and presence of infection (transient
hematuria.
 Epithelial cells
 Casts
 Bacteria
 Yeast parasites
 Mucus
 Spematozoa
 Crystals
 Artifacts
 Least standardized, most time-consuming

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 Refrigeration precipitates crystals.

 Upper: RBC in fresh urine are red with a smooth  Less contamination (epithelial cells) from a midstream
texture. In dog urine, they are slightly biconcave clean-catch specimen.
(arrows). Lower: RBCs in stored urine can crenate  Mix specimen before decanting to the centrifuge
taking on a spiky appearance (arrows). The colorless tube.
grainy round cells in amongst the RBC are WBC in this
urine from a cat with cystitis. SPECIMEN VOLUME
 Centrifuge 10–15 mL urine (reagent strips fit into 12
MACROSCOPIC SCREENING / CHEMICAL SIEVING mL).
 Microscopic is performed based on physical and  Always cap tubes.
chemical results.  Too little volume = fewer formed elements.
 Color, clarity, blood, protein, nitrite, leukocyte  Some laboratories correct for volume.
esterase, and possibly glucose.
 Special populations: pregnant women; pediatric,
geriatric, diabetic, immunocompromised, renal CENTRIFUGATION
patients.  Standardize speed and time of centrifugation
 5 min. at relative centrifugal force (RCF) of 400
CLINICAL AND LABORATORY STANDARDS INSTITUTE is ideal
(CLSI)  RCF corrects for variations in the diameter of
 Requested by the physician.  centrifuge heads; revolutions per minute does
 Laboratory-specified population. not (specimen should always be properly capped)
 Any abnormal physical or chemical result.  Do not brake the centrifuge
 Laboratory criteria are programmed into automated
instrumentation. POST CENTRIFUGE SEDIMENT
 0.5–1.0 mL after decantation
SEDIMENT STANDARDIZATION  Concentration factor: volume of urine
 Preparation of sediment centrifuged/sediment volume
 Volume of sediment examined o Probability of detecting low quantities of
 Methods of visualization formed elements
 Reporting of results  Aspirate rather than pour off urine (pipettes available
 Commercial systems: KOVA for this)
o Calibrated centrifuge tubes, special slides to  Mix sediment gently, not vigorously (mix when urine is
control volume, decanting pipettes, grids for removed and its sediments)
better quantitation
VOLUME OF SEDIMENT EXAMINED
MACROSCOPIC SCREENING CORRELATIONS\  Be consistent
 Commercial systems control this
SCREENING TEST SIGNIFICANCE  Glass slide method:
o 20 μL
Color Blood o Cover it by a 22 x 22 glass cover slip
Clarity Hematuria verus o Do not overflow cover slip
hemoglobinuria/myoglobinuria  Heavier elements (casts) flow
Confirm pathologic or outside
nanpathologiv cause of
EXAMINATION OF SEDIMENT
turbidity
 Be consistent
Blood RBCs/RBC casts  Minimum 10 lpfs and 10 hpfs
 Low power: casts, general composition
Protein Casts/cells o Scan edges for casts with glass slide method
 High power: identification
 Initial focusing: low power, reduced light
Nitrite Bacteria/WBCs o Focus on epithelial cell, not artifacts that are
in a different plane
Leukocyte WBCs/WBC casts/bacteria  Use fine adjustment continuously for best view
esterase
Glucose Yeast ARTIFACT INTERFERENCE
 Large pollen grain
 No usual sediment elements in view
 Grain is in a different liquid plane than the
SPECIMEN PREPARATION
urine constituents due to its larger size
 Examine when fresh or preserved.
 RBCs, WBCs, casts lysed in dilute, alkaline urine.

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Fluorescence microscopy Allows visualization of

naturally fluorescent
microorganisms or those
stained by a fluorescent
dye (used in
immunology)
Interference-contrast Produce a three-
dimensional
microscopy–image and
layer-by-layer imaging of
a specimen
MICROSCOPIC REPORTING
 Consistent within laboratory CARE OF THE MICROSCOPE
o Rare, few, moderate, many, or full field or 1+,  Carry microscope with two hands, supporting the
etc. –semiquantitative (squamous cells, base with one hand.
mucous )  Always hold the microscope in a vertical position.
 Casts: average per lpf  Only clean optical surfaces with a good quality lens
 RBCs, WBCs: average per hpf tissue and commercial lens cleaner.
 Epithelial cells, crystals, etc., in semiquantitative terms  Do not use the 10x and 40xobjectives with oil.
 Clean the oil immersion lens after use.
SEDIMENT STAINS  Always remove slides with the low-power objective
 Low refractive index elements are often difficult to raised.
see under bright-field microscopy  Store the microscope with the low-power objective in
 Supravital stain: crystal violet and Safranin O (also position and the stage centered.
Sternheimer-Malbin (SM) stain)
o Most common SEDIMENT CONSTITUENTS
o Increases refractive index
 Many urines have just a rare epithelial cell
o Stains nuclei, cytoplasm, inclusions
 Small amounts of constituents can be normal or
o Sedi-Stain, KOVA stain, etc.
pathogenic based on the clinical picture
o Toluidine blue o appearance of small numbers of the usually
 Acetic acid will enhance WBC nuclei
pathologically significant RBCs, WBCs, and casts
 Lipid stains
can be normal.
o Oil Red O and Sudan III for triglycerides and
 Some constituents are easily distorted
neutral fats; cholesterol polarizes (based on
 Commonly listed values:
solubility)
o 0-2 or 3 RBCs per hpf
 Gram stain o 0-5 or 8 WBCs per hpf
o Identification of bacterial casts
o 0-2 hyaline casts per lpf.
 Hansel stain
o Urinary eosinophils
o Methylene blue and eosin Y: better than
Wright stain
 Prussian blue stain
o Hemosiderin granules seen with
hemoglobinuria

MICROSCOPY

Technique
Bright-field microscopy
Phase-contrast microscopy
Polarizing microscopy
Dark-field microscopy
Function
Used for routine urinalysis
Enhances visualization of
elements with low
refractive indices, such
as hyaline casts, mixed
cellular casts, mucous
threads and
Trichomonas
Aids in identification of
cholesterol in oval fat
bodies, fatty casts, and
crystals
Aids in identification of
Treponema pallidum
RED BLOOD CELLS
 Smooth, non-nucleated, biconcave disks
 Crenated in hypersthenuric urine
 Ghost cells in hyposthenuric urine
 Identify using high power
 Most difficult for students to recognize due to:
o RBCs lack of characteristic structures
o Variations in size
o Close resemblance to other urine constitunets
 Should the identification continue to be doubtful,
adding acetic acid to a portion of the sediment will

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lyse the RBCs, leaving the yeast, oil droplets, and

WBCs intact.
 Supravital staining may also be helpful.

OIL
DROPLET

 Dysmorphic RBCs (RBCs that vary in size, have cellular

protrusions, or are fragmented)
o Glomerular bleeding
o Strenuous exercise
o Acanthocytic, blebs
o Fragmented, hypochromic
o Aid in diagnosis

CLINICAL SIGNIFICANCE
 Normal value: 0–3 or 5/hpf
 Damage to glomerular membrane or vascular injury
to the genitourinary tract
 Number of cells = extent of damage
 Macroscopic versus microscopic hematuria
o Cloudy, red urine, advanced disease, trauma,
acute infection, coagulation disorders
o Clear urine, early glomerular disease,
 Identification difficulties: malignancy, strenuous exercise, RENAL CALCULI
o Yeast: look for buds confirmation
o Oil droplets: refractility
o Air bubbles: refractility and possibly in a different NOTE!!!
plane  The presence of not only RBCs but also hyaline,
o Starch: refractile, polarizes granular, and RBC casts may be seen following
o Reagent strip correlation strenuous exercise. These abnormalities are
nonpathologic and disappear after rest.
 The presence or absence of RBCs in the urine
sediment cannot always be correlated with
specimen color or a positive chemical test result for
blood.
 The presence of hemoglobin that has been filtered
by the glomerulus produces a red urine with a
positive chemical test result for blood in the absence
of microscopic hematuria. Likewise, a specimen
appearing macroscopically normal may contain a
YEAST small but pathologically significant number of RBCs
when examined microscopically.

AIR
BUBBLE
E

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WHITE BLOOD CELLS

 Neutrophil is predominant
 Identify under high power
 Glitter cells
o Hypotonic urine
o Brownian movement
o Swell; granules sparkle
o Pale blue if stained
o Nonpathologic

 Drug-induced interstitial nephritis

 Renal transplant rejection

HANSEL STAIN
 Used to stain eosinophil
 Percent per 100–500 cells
 >1% significant
o At least 2 eosinophil in 100 cells is significant
o Disease:
 Concentrate sediment, centrifuge, or cytocentrifuge

MONONUCLEAR CELLS
 Lymphocytes, monocytes, macrophages, histiocytes
(tissue macrophages) are rare
 Differentiate from renal tubular epithelial (RTE) cell
o Significant, more than 2 of RTE in urine indicates
problems in renal tubules
 Lymphocytes may resemble RBCs; seen in early
transplant rejection
 May need to refer to cytodiagnostic testing
o Usually under anatomic lab, performed in
histopath
o Mononuclear have single nuclei, round.

NOTE!!!
 Neutrophil vs mononuclear cells
 Neutrophils are bilobed and nuclei fragments can be
seen while mononuclear cells have single nucleiand
round.

CLINICAL SIGNIFICANCE
 Normal = <5 per hpf, more in females
o Higher indicate infection
 May enter through glomerulus or trauma but also by
amoeboid migration
o e.g in gomerular bleeding with RBC and WBC
(round)
 Increased WBCs = pyuria
 Infections: cystitis, pyelonephritis, prostatitis, urethritis
o White cells specially mononuclear cells,
macrophages, polymorphonuclear cells are
o Red cells (7um) are smaller than wbc (12-15um)
amoeboid because during infection they
o RBC are double walled and clean while WBCs
migrate to circulation to tissue, sometimes, they
are granular
are removed from attachment and washed out
o Wbc are bilobed, hypersegmented nucleus
to urine.
o Acetic Acid is used to enhance the nuclei of
o Cystitis – an infection of the bladder, lower UTI
WBC, and is used when there is a lot of RBC
o Pyelonephritis – involves kidney, upper UTI
which makes other elements not visible. It lyse
 Non- infection: Glomerulonephritis, lupus
RBC.
erythematosus, interstitial nephritis, tumors
 Report presence of bacteria
EIOSINOPHIL

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EPITHELIAL CELLS CLUE CELLS

THREE TYPES:  Squamous cell with pathologic significance
 Squamous – usually not significant  Gardnerella vaginalis vaginal infection
 Transitional (urothelial) – shapes: spherical, caudate  Coccobacillus covers most of the cell and
cuboidal extends over the edges
 RTE- - Renal tubular epithelial cells shapes/forms :  Seen in urine but more common in vaginal wet
columnar cuboidal, round depends on where it preparation
came from
TRANSITIONAL (UROTHELIAL) CELLS
CLASSIFICATION: THREE FORMS:
 Squamous – vagina, male and female urethra  Spherical: absorb water in bladder and become
 Usually not significant large and round
 Transitional – bladder, renal pelvis, calyces, ureters,  Caudate: appear to have a tail
upper male urethra o like T. vaginalis
 RTE – Renal tubules shapes depends kung saang  Polyhedral: multiple sides
renal tubules sila galing hehe.
o RTE eccentric nucleus, transitional centrally DIFFERENTIATE FROM RTE
located nucleus.  Centrally located nucleus - Transitional (Urothelial)
Cells
o Eccentric nucleus – RTE

SYNCYTIA = CLUMPS
 Catheterization
 Malignancy

SQUAMOUS EPITHELIAL CELLS

 Largest cell in urine
 Good for focusing microscope
 Semi quantitative reporting: Rare, few, moderate,
many
 lpf or hpf per laboratory
 Normal sloughing of epithelial cells
 Contamination if not midstream clean-catch – to
retrieved lower amount

RTE CELLS
 Size and shape vary with renal tubular area
 Basis of the location is the shape
 Columnar = proximal convoluted tubule (PCT)
 Round, oval = distal convoluted tubule (DCT)

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o Can be mistaken as urothelial cells but to

differentiate it from RTE look at its nucleus. If its
eccentric then its RTE.
 Cuboidal = collecting duct
o Clumps of RTE is often seen
 Three or more cuboidal cells = renal fragment

CLINICAL SIGNIFICANCE
 They all came from the renal tubule
 They can be normal or due to a condition for
example there is damage in the kidney tubules.
o Patients with hemolytic disorder, kidney tubules COLLECTING DUCT RTES
exposed in hemoglobin then there is retention of  Cuboidal, never round
urine or urine stasis. Too much exposure will lead o At least one straight edge
to damage because hemoglobin is toxic to our o Eccentric nucleus
renal tubules.  Three or more cells in clump is renal fragment; often
large sheets
PCT CELLS  PCT and DCT not seen in clumps
 Larger than other RTEs
 Cells from the proximal convoluted tubule
 Columnar, convoluted, rectangular
 They are also called convoluted epithelial renal cells
 May resemble casts
o Because of the granular cytoplasm but to
differentiate it from PCT look at the eccentric
nuclei
 Coarsely granular cytoplasm
 Notice presence of nucleus

DCT CELLS
 Round or oval-shaped, smaller
 Cells from the distal convoluted tubule
 May resemble WBCs or spherical transitional cells or
urothelial cells
o To differentiate it from spherical transitional cells
look at the nucleus, DCT cells nucleus is eccentric
while spherical transitional cells are centrally
located
o To differentiate it from WBC look at the size, DCT
cells are bigger
 Observe the eccentrically placed nucleus to
differentiate from spherical transitional
CLINICAL SIGNIFICANCE
 When we see more than 2 RTE cells in the urine then
its clinically significant
 RTE cells are the most clinically significant urine
epithelial cells; indicate tubular necrosis; fragments
indicate severe destruction
o Heavy metals, drug toxicity, hemoglobin,
myoglobin, viral infections, pyelonephritis,
transplant rejection, salicylate poisoning
 Single cuboidal cells = salicylate poisoning
 Absorb: bilirubin, hemoglobin, lipids
o When they absorb fluids they are called oval fat
bodies
 Hemosiderin stains with Prussian blue

OVAL FAT BODIES

 RTE cells that have absorbed lipid in the filtrate
 Also free-floatingrefractile droplets
 Maltese cross formation with polarized light
 If negative check with Sudan III or oil red O stain

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o When they stain red o it can be triglycerides or
neutral fats
 Stain polarizing negative structures
 Cholesterol polarizes
 Triglycerides and neutral fats stain
 Lipiduria: nephrotic syndrome, acute tubular necrosis,
diabetes, crush syndromes
BACTERIA
 Urine is usually sterile, contaminated on the way out;
contaminants multiply fast
 WBCs should accompany bacteria in UTI
 Report few, moderate, many per hpf
 Rods and cocci may be seen; rods most common
 Nitrite helps to confirm rods, not cocci
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YEAST
 Single, refractile, budding structures
 Mycelial forms may be present
 Report: few, moderate, many
 Diabetic urine: ↑glucose and acid ideal for yeast
growth
 Immunocompromised, vaginal moniliasis, HIV patients
 Nitrite negative, WBCs present
 Confuse with RBCs
o Difference is yeast have budding and more
refractile than the red cells
PARASITES
 Most common: Trichomonas vaginalis
o Pear-shaped flagellate
o Swims across field very rapidly
o Patients who have T. vaginalis infection often
complain for itching
 Report: few, moderate, many
o Semi-quantitative reporting
 If not moving, it may resemble WBC, transitional, or
RTE cells
o Transitional epithelium specially the caudate
 Other parasite: Schistosoma haematobium and
Enterobius vermicularis
o Schistosoma haematobium: has terminal spine
o Enterobius vermicularis (pinworm): egg is D shape
and hatch in rectum that’s why it can be
sometimes see in urine.
SPERMATOZOA
 You can see spermatozoa in female/ male patients
o Male (significant): in determination of fertility
 There is retrograde ejaculation- Urine and
semen have only one way out. In normal
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 MICROSCOPIC EXAMINATION OF URINE
patients, if they ejaculate, the semen would
directly come out of the penis as the
sphincter within the bladder closes. But in
males with this situation, the sphincter in the
bladder is damage and do not close, so
when they ejaculate, instead of going out
directly in the penis, semen goes into the
bladder. That is why if the patient urinates, his
urine contains some sperm. People suffering
from this are normally infertile.
 Oval, tapered heads and long tail
 Urine is toxic to sperm, so they are immobile
 Rarely significant, infertility: sperm expelled into
bladder instead of urethra
 May cause positive protein
o Due to the content of semen
 Reporting varies with laboratories
o When seen in teenage female patients, you
usually do not report it.
o In male patients, when it is used to check for
infertility, you report.
o For young children’s female patients, it might be
an indication that they are a victim of rape.
 Lack of clinical significance, legal consequences.
 Legal consequences are aligned to child patients
results. You might be called in the court to report
what you saw that might be useful evidence for rape
cases.
MUCUS
 Protein produced from RTE, glands, squamous cells
o Normal and usually not significant
o Present in high amounts specially in females
 Threadlike, low refractive index
 Sometimes Confused with casts but not that often
since
o Irregular, composed of Tamm-Horsfall (TH) protein
 Tamm-Horsfall (TH) protein or also called
‘Uromodulin’, is the major component of
mucus, and the matrix that form the urinary
casts.
o Mucus shape is bizarre unlike cast that are
formed and normally cylindrical
o It also does not have granules inside like casts
 Commonly seen in Female specimens, but have no
clinical significance
 Like squamous epithelial, sometimes they are a
nuisance to the specimen as they obscure important
elements that need to be seen.
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CASTS
 Elements unique to the kidney
o Unlike other elements like RBC that could came
from the circulation when glomerulus is damage
or the kidney when there is presence of kidney
stones. It can be renal or non-renal in origin unlike
Casts that are only Renal.
 Formed in Distal Convoluted Tubule (DCT) and
collecting duct
o Casts imitate the form of tubules
o Shape: usually long in cylindrical
 Have Parallel sides, rounded ends, inclusions
o RBC casts: casts that contain RBC
o WBC casts: casts that contain WBC
 Detect under low power, Identify under high power
o After detecting the under low power, you need
to view then under high power in order to identify
what type of casts it is.
 Identification is according to the inclusion
bodies it contains (RBC, WBC, granules,
bacterial, etc.)
 Scan edges of glass coverslip
o When doing slide method for examining urine
sediments, you need to scan the edges of the
cover slip since casts are heavy that is why it
goes to the corners of the cover slip.
o Scan edge to not miss casts presence.
 Low light is essential
o Specially in hyaline casts that has low refractive
index and hard to visualize.
 Report number per lpf
o Note that hpf is only for identification
 Many pathologic and nonpathological causes
o Non-pathologic:
 hyaline casts and RBC casts can be seen in
extraneous exercise.
o Pathologic:
 presence of RBC casts and significant
amount of RBC may be due to a glomerular
damage.
 Presence of WBC, bacterial casts, (+) LE, and
(+) nitrite might indicate pyelonephritis.
COMPOSITION AND FORMATION
 Tamm Horsfall (TH) protein or Uromodulin secreted by
RTE of DCT and collecting duct
o Matrix components of casts is mainly composed
or uromodulin
 Consistent excretion normally
o ↑ stress and exercise
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 MICROSCOPIC EXAMINATION OF URINE

 In strenuous exercise, we can have HYALINE CASTS

physiologic appearance of casts  Low refractive index
(nonpathological) o That is why it is viewed under low light or PCM
 Formation of TH protein fibrils into matrix  Colorless when unstained
o Factors that favor Urinary casts formation:  Use low light or phase contrast microscope
 Urine stasis: there’s urine retention (that’s why o Since material is unstained
it’s not good to hold back urine as you’ll  Normal parallel sides or convoluted, wrinkled,
become more prone to have UTI) cylindroid, occasional adhering cell or granule
 acid pH o Since it was already a dehydrated cast, the
 Presence of Na and Ca contents are already removed.
 TH protein not detected by reagent strips;
o ↑ protein is from renal disease
 If ever that there are elevated levels of
mucus threads, hyaline casts—the protein
may still be negative. But in cases in which
these are high in levels and your result for
protein in chem exam is increased, it’s not
because of the high presence of TH protein,
but it is because of renal disease.
**(Since TH is not detected by reagent strip)
 Formation:
o Aggregated TH fibrils attached to RTEs
 It attached in our kidney tubules
o Interweaving to loose network, and traps
elements
 E.g in patients that have glomerular
bleeding, in the tubules where TH protein is
presence and form the matrix, it traps the
RBC that pass through it. That is why
glomerular bleeding is indicated by
presence of RBC and RNBC casts.
 If your tubules are very damage, it even traps
WBC.
 In patients experiencing Pyelonephritis
(Upper UTI), there is a formation of TH fibrils
and proliferation of WBC in the area of
infection that would eventually trap WBC.
That is why we have WBC in our urine.
 In Pyelonephritis (Upper UTI) we can
have WBC casts, bacteria casts, and
bacteria can be positive in nitrate exam
and LE, which are not present in Cystitis
(Lower UTI) since it was in the bladder.
***Take note that casts in unique to the
o Disintegrating Hyaline casts (right figure)
kidney, in which the Pyelonephritis is
o Has jogged edges
located.
o Maybe because it stayed in the tubules for too
 Pyelonephritis (Upper UTI)—infection with
long.
presence of WBC casts
o This usually happen when we have urine
 Cystitis (Lower UTI)—infection without the
retention.
presence of WBC casts
o In patients that have renal damage that exhibit
o More interweaving to form solid matrix
urine statis.
o Attachment of elements to matrix
o This cast can disintegrate and become granular
o Detachment of fibrils from RTEs
casts/ waxy casts.
 If the matrix is already full of content, it will
now depart from the lining of the tubules or
CLINICAL SIGNIFICANCE
RTE.
o Excretion of cast in our urine  Most frequently seen
 Cylindroids  0–2 is normal
o Tapered ends, one or both (right one)  Nonpathologic: stress, exercise, fever, heat exposure,
 Casts have parallel sides/ rounded edges dehydration
(left one)  Pathologic: glomerulonephritis, pyelonephritis,
o Same significance as cast chronic renal disease, congestive heart failure

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Figure: Hyaline cast containing occasional granules
(x400)
Figure: Hyaline cast and amorphous urates attached to
mucus pseudocast.
RBC CASTS
 Orange-red color
 Embedded and adhering cells
 May be fragmented
 Confirm seeing free RBCs and positive reagent strip
for blood
 Look for cast matrix to avoid mistaking a RBC clump
for a cast
Figure: RBC cast. Notice the presence of hypochromic
and dysmorphic free RBCs (x400).
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Figure: KOVA-stained RBC cast under phase microscopy
(x400).
CLINICAL SIGNIFICANCE
 Bleeding within the nephron, casts are more specific
than free RBCs in urine
 Glomerular damage or nephron capillary damage
 Glomerular damage: dysmorphic RBCs and elevated
protein
 May be seen following strenuous exercise
 Cells begin to disintegrate with more stasis of urine
flow
 Hemoglobin and myoglobin damage tubules
 Hemoglobin degraded to methemoglobin = dirty
brown casts
 Look for RTE cells to confirm tubular necrosis
Figure: Disintegrating RBC cast. Notice the presence of
free RBCs to confirm identification.
Figure: Cast containing hemoglobin pigment. A
comparison of RBCs and yeast also can be made
(x400).
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 MICROSCOPIC EXAMINATION OF URINE
Figure: Granular, dirty brown cast (x400).
WBC CASTS
 Mostly neutrophils and lobed nucleus and granules
are seen
 Staining helps differentiate from RTE cells
 May be tightly packed; look for cast matrix to
distinguish from WBC clump
Figure: KOVA-stained WBC cast (x400).
Figure: WBC clump. Notice the absence of a cast matrix.
 WBC casts are seen with infection and inflammation
of the tubules
 Pyelonephritis: WBC casts, bacteria
 Acute interstitial nephritis: WBC casts, no bacteria
 May accompany RBC casts
Figure: Disintegrating WBC cast (x400).
BACTERIAL CASTS
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FLORIA, LIM, PANALIGAN, RICAMORA
 May be pure bacteria or mixed with WBCs
 Resemble granular casts
 Look for free WBCs and bacteria
 Confirm with Gram stain
 Seen in pyelonephritis
 Mixed cellular casts
o Glomerular nephritis: RBCs and WBCs
 Look for predominant type of cell
EPITHELIAL (RTE) CASTS
 Formed in DCT = small, round cells
 Fibrils forming cast pull cells from damaged tubules
 Majority of cells are on the cast matrix
 Differentiate from WBCs: stain to show single nucleus
Figure: RTE cell cast (x400).
Figure: KOVA-stained RTE cell cast (x400).
CLINICAL SIGNIFICANCE
 Tubular damage, due to exposure of tubules to
heavy metals, viral infections, drug toxicity, graft
rejection, pyelonephritis
o Severed tubules
 Cells may appear bilirubin-stained or brown color –
e.g patient with hepatitis
 Look for matrix to distinguish fragments
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 MICROSCOPIC EXAMINATION OF URINE

FATTY CASTS
 Seen with oval fat bodies (OFBs) and fat droplets
 Highly refractile, OFBs may attach to matrix
 Polarized microscopy and lipid stains – visible
polarization specially cholesterol component
 Can see them Nephrotic syndrome, diabetes, crush
trauma, tubular necrosis

GRANULAR CASTS
 Coarse and finely granular o Waxy cast (highly refractile) is different from
o It lab just report granular hyaline (faint)
 Granule origin:
• RTE lysosomes, excreted in normal metabolism, WAXY CASTS
more after exercise and activity  E.g patient with renal failure
 Disintegration of cellular casts and free cells  Brittle, highly refractile
 Detect with low power, ID with high power  Often fragmented with jagged ends and notches
 Granules disintegrate to form waxy casts  Well visualized with stain
 Differentiate granular casts from clumps of debris and  Degenerated hyaline and granular casts
crystals; look for matrix.  Extreme urine stasis
 Renal failure

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 MICROSCOPIC EXAMINATION OF URINE
BROAD CASTS
 Renal failure casts
 Destruction and widening of the DCTs
 Formation in the upper collecting duct
 All types of casts may be broad
 Most common are granular and waxy
 Bilirubin stained from viral hepatitis
URINARY CRYSTALS
 Common, most are not clinically significant but are
reported
 Must differentiate from the few abnormal crystals
indicating liver disease, inborn errors of metabolism ,
and damage to tubules.
o presence of cysteine crystals - - cystinuria
o tyrosine crystals –
APOSTOL, ALLAUIGAN, ATAL, BARANGAN, BAYER, DIAZ,
FLORIA, LIM, PANALIGAN, RICAMORA
o Fanconi syndrome – cysteine in renal tubules
they can impair reabsorption capacity of tubule
causing damage in tubules.
 Iatrogenic: caused by medications or treatments
o E.g sulfa crystals- uti drugs.
o ampicillin crystals – antibiotic
 Report: rare few, moderate, many
Increase amount may indicate presence of renal
calculi and kidney stones.
CRYSTAL FORMATION
 Precipitation of urine solutes: salts, organic
compounds, and medications
o Organic crystals seen in acidic
o Inorganic crystals seen in alkaline except
calcium oxalate which can be seen in neutral
and acidic
 Formation based on temperature, solute
concentration, and pH
o Temperature – most crystals precipitate at low
temperature
o Solute concentration – the higher the solute, the
ability of crystals to form are more enhance. To
avoid precipitation: patient should be well
hydrated –because when urine is very
concentrated and has a much of solute, this
solute will not stay in solution rather they will
attach themselves together.
o pH- crystals can be formed in alkaline or acidic
urine
 Many crystals in refrigerated specimens
o Amorphous urates precipitate when urine is
refrigerated, pinkish in color due to uroerythrin.
• High specific gravity needed in fresh specimens
GENERAL IDENTIFICATION (ID)
 Most have characteristic shapes and colors
 Most valuable ID is urine pH
 Classification: normal acid, normal alkaline
 All abnormal crystals are found in acid urine
 Polarized microscopy characteristics are
valuable in ID
SOLUBILITY CHARACTERISTICS
 Temperature and pH contribute to formation
and solubility
 Amorphous urates form in refrigerated acid
urine; will dissolve with heat
 Amorphous phosphates form in refrigerated
alkaline urine; will dissolve in acetic acid; so
will RBCs
NORMAL CRYSTALS IN ACID URINE
 Amorphous urates
 Yellow-brown granules microscopically
 Urine sediment has pink color due to the pigment
 uroerythrin attaching on surface of granules
 Often in clumps; may resemble casts
 pH usually greater than 5.5
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 MICROSCOPIC EXAMINATION OF URINE

\
URIC ACID CRYSTALS
 Rhombic, whetstones, wedges, rosettes NORMAL CRYSTALS IN ALKALINE URINE
 Yellow-brown color  Triple phosphate
 May resemble cystine crystals but always polarize  Colorless, prism, or coffin-lid shaped
 ↑ purines, nucleic acids  Highly alkaline urine and urinary tract infections
(UTIs)
 Polarize
 No clinical significance

AMORPHOUS PHOSPHATES
 May appear similar to amorphous urates
 Differentiate: Alkaline pH and heavy white
precipitate after refrigeration

CALCIUM OXALATE CRYSTALS

 Acid and neutral pH
 Dihydrate is envelope or two-pyramid–shaped
 Most common
 Monohydrate is oval or dumbbell-shaped
 Antifreeze poisoning
 Calcium oxalate is a major component of renal
calculi
CA PHOSPHATE AND CARBONATE
 Ca Phosphate and Carbonate
o Flat rectangles and thin prisms in rosettes
o Mistaken as sulfonamide crystals
o Dissolves with acetic acid
o No clinical significance
 Carbonate
o Small, dumbbell, and spherical shapes
o Gas produced with addition of acetic acid
o No clinical significance

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 MICROSCOPIC EXAMINATION OF URINE

CHOLESTEROL CRYSTALS
 Refrigerated specimens
 Lipid that are remaining in droplet forms especially in
lowtemperature
 Rectangular plates with characteristic notched
corners
 Highly birefringent
 Nephrotic syndrome accompanying fatty casts and
OFBs

AMMONIUM BIURATE CRYSTALS

 Yellow-brown, spicule covered spheres; ―thorny
apples”
 Only urates in alkaline urine
 Kamukha ng acid urine
 Old specimens and with urea-splitting bacteria

ABNORMAL CRYSTALS
 Cystine crystals
o Hexagonal, thin and thick plates
o Similar to uric acid
LIVER DISEASE CRYSTALS
o UA polarizes but only thick cystine crystals
 Bilirubin crystals
polarize
o Clumped needles or granules
o We can use polarizing microscope to identify
o Characteristic yellow color
o Non-birefringent except when the cystine crystals
o Seen in patients with viral hepatitis with tubular
are thick
damage
o Seen in cystinuria— inability to reabsorb cystine
o Positive reagent strip for bilirubin
o It will lead to necrosis
 Tyrosine crystals
o Confirm: cyanide nitroprusside test- can be an
o Fine yellow needles in clumps or rosettes
aid to determine the presence of cystinuria
o Seen with leucine crystals
o Inherited amino acid disorders

 Leucine crystals
o Yellow-brown spheres with concentric circles and
radial striations
o Bilirubin positive reagent strip for both

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 MICROSCOPIC EXAMINATION OF URINE

IATROGENIC CRYSTALS
 This crystals are formed from the excess amounts of HAIR FOLLICLE
drugs being taken by the patients
 Ampicillin crystals
o Colorless needles that form bundles after
refrigeration
o High( ↑) dosage, low ↓ hydration

DIAPER FIBER

 Sulfa crystals
o Most common to precipitate
o Variety of shapes
o Patient treated for UTI

REFERENCES

Notes from the discussion by Prof. Ethel Marie

 Radiographic dye Mangada, RMT
o Similar to cholesterol crystals, polarize
o Patient history
Cagayan State University PowerPoint presentation
o Very high Specific Gravity (>1.040) with
refractometer
o But when reagent strip used will remain
unaffected
ARTIFACTS RESEMBLING CASTS
 Material fibers, meat and vegetable fibers, and hair
 Casts do not polarize except fatty casts
 Many fibers polarize
 Top picture is vegetable fiber
 Middle picture is hair
 Bottom picture is diaper fiber

VEGETABLE FIBER

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