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Urinalysis - Giovanni Fogazzi
Urinalysis - Giovanni Fogazzi
1052 American Journal of Kidney Diseases, Vol 51, No 6 (June), 2008: pp 1052-1067
Core Curriculum in Nephrology 1053
Table 1. Example of Instructions for Urine Collection or crystals. In our experience, urinary infection
and contamination caused by genital secretions
Avoid strenuous physical exercise (eg, running or a
soccer match) in the 72 hours preceding the collection are the most frequent causes of urine turbidity.
to prevent exercise-induced proteinuria and/or It must be remembered that pathological
hematuria or cylindruria. samples can be perfectly clear.
Avoid urinalysis during menstruation because blood
contamination can occur, which can erroneously lead Odor
to a diagnosis of hematuria.
In case of mild genital discharge (eg, leukorrhea), use Infection also is the most frequent cause of
internal tampons to prevent contamination. abnormal pungent odor of urine, which is caused
Wash your hands. by the production of ammonia by bacteria. The
Wash the urethral meatus after spreading the vulvar labia following rare pathological conditions confer a
(female) or withdrawing the foreskin of the glans (male)
and wipe with a towel.
specific odor to the urine: maple syrup urine
Collect the urine after discarding the first portion of disease (maple syrup odor), phenylketonuria
micturition (midstream technique) to reduce (musty or mousy odor), isovaleric acidemia
contamination from urethral and/or vaginal cells and (sweaty feet odor), and hypermethioninemia (ran-
secretions. cid butter or fishy odor). Ketones may confer a
Close the container completely and write your name
clearly and in full on the label.
sweet or fruity odor.
Relative Density
gium]) can be used as preservatives of urine Relative density can be measured by using
particles. However, preservatives can alter the different methods:
appearance of particles. Thus, every effort should
Specific Gravity
be made to examine samples within 2 to 4 hours
from collection. For this reason, in our labora- This is a function of the number and weight of
tory, we usually examine samples within 2 to 3 dissolved particles. It usually is measured by
hours from collection. We only use formalde- using a urinometer, which is a weighted float
hyde or cellFIX to preserve particles for teaching marked with a scale from 1.000 to 1.060. The
purposes. urinometer is simple and quick to use, but today,
it is outdated.
ADDITIONAL READING
Osmolality
1. Kouri T, Fogazzi GB, Vania G, et al: European
urinalysis guidelines. Scand J Clin Lab Invest 60:S1-S96, This represents the gold-standard method. It
2000 (suppl 231) depends on the number of particles present and is
2. NCCLS: Urinalysis and Collection, Transportation and
Preservation of Urine Specimens; Approved Guideline (ed
2). NCLLS document GP16A, 2001 Table 2. Main Causes of Abnormal Color Changes
3. Van der Snoek BE, Koene RAP: Fixation of urinary in Urine
sediment. Lancet 350:933-934, 1997
Pathological Gross hematuria, hemoglobinuria,
PHYSICAL PARAMETERS conditions myoglobinuria (pink, red, brown, black)
Jaundice (yellow to brown)
Color Chyluria (white milky urine)
Massive uric acid crystalluria (pink)
In normal conditions, the color of urine ranges Porphyrinuria, alkaptonuria (red to black
from pale to dark yellow and amber. Abnormal upon standing)
color changes can be caused by pathological Drugs Rifampin (yellow-orange to red)
conditions, drugs, and foods (Table 2). Phenitoin (red)
Chloroquine, nitrofurantoin (brown)
Turbidity Triamterene, blue dyes of enteral feeds
(green)
Normal urine usually is transparent. Urine can Metronidazole, methyldopa, imipenem-
be turbid because of an increased concentration cilastatin (darkening upon standing)
of any urine particle, but especially erythrocytes, Foods Betroot (red)
Senna, rhubarb (yellow to brown, red)
leukocytes, bacteria, squamous epithelial cells,
1054 Fogazzi, Verdesca, and Garigali
measured by using an osmometer. High glucose a homogenous diffuse green pattern. The latter
concentrations significantly increase osmolality may be caused by marked hematuria because of
(10 g/L of glucose ⫽ 55.5 mOsmol/L). the high number of erythrocytes that cover the
entire pad surface or by lysis of erythrocytes,
Refractometry which can occur on standing or because of alka-
This is based on measurement of the refractive line urine pH and/or low relative density.
index, which depends on the weight and size of The most important false-positive results oc-
solutes per unit volume. Today, refractometry is cur for the presence of hemoglobinuria (from
used widely because it is simple, requires only 1 intravascular hemolysis), myoglobinuria (from
drop of urine, and has good correlation with rhabdomyolysis), or high concentration of bacte-
osmolality. ria with pseudoperoxidase activity (Enterobacte-
riaciae species, Staphylococci species, and Strep-
Dry Chemistry tococci species).
This is the method incorporated into dipsticks. False-negative results are mainly caused by
In the presence of cations, a complexing agent ascorbic acid, a strong reducing agent, the pres-
releases protons, which produce a color change ence of which can result in a low-grade micro-
of the indicator bromthymol blue. Because of its scopic hematuria being completely missed. In
simplicity, this method is the most used. How- such cases, although dipstick results are nega-
ever, it should be remembered that underestima- tive, microscopy shows hematuria.
tion occurs with urine pH greater than 6.5, Detection of hemoglobin by means of dipstick
whereas overestimation is found with urine pro- has 95% to 100% sensitivity and 65% to 93%
tein concentration greater than 7.0 g/L. In addi- specificity.
tion, it is not sensitive to nonionized molecules,
such as glucose and urea. Thus, it is not surpris- Glucose
ing that it has poor correlation with results ob- With a dipstick, glucose is first oxidized to
tained by using osmolality and refractometry. gluconic acid and hydrogen peroxide. Then,
through the catalyzing activity of a peroxidase,
CHEMICAL PARAMETERS hydrogen peroxide reacts with a reduced color-
less chromogen to form a colored product. This
pH
test is sensitive to concentrations of 0.5 to 20
In routine practice, pH most commonly is g/L. When more precise quantification of urine
measured by means of dipstick. This is based on glucose is needed, such enzymatic methods as a
an indicator that covers the pH range 5.0 to 8.5 to hexokinase must be used.
9.0. With this method, significant deviations from False-negative results occur in the presence of
true pH are observed for values less than 5.5 and ascorbic acid and bacteria, whereas false-posi-
greater than 7.5. Therefore, a pH meter with a tive findings may be observed in the presence of
glass electrode is mandatory when accurate mea- oxidizing detergents and hydrochloric acid.
surement is necessary.
In addition to its application in clinical prac- Protein
tice, measurement of urine pH is needed for Three different approaches can be used for the
correct interpretation of urinary microscopy find- evaluation of proteinuria (Table 3).
ings (see microscopy).
Dipstick
Hemoglobin It is based on the principle of the protein error:
Hemoglobin also usually is detected by means the presence of protein in a buffer causes a
of dipstick. This is based on the pseudoperoxi- change in pH that is proportional to the concen-
dase activity of the heme moiety of hemoglobin, tration of protein itself. Thus, dipstick changes
which catalyzes the reaction of a peroxide and a its color from pale green to green and blue
chromogen to produce a colored product. The according to pH changes induced by the protein.
presence of hemoglobin produces either green This method is sensitive to albumin (detection
spots, which are caused by intact erythrocytes, or limit, ⬃0.020 to 0.025 g/dL [0.20 to 0.250 g/L]),
Core Curriculum in Nephrology 1055
proteinuria during
Limitations
In addition, dipstick allows only an approxi-
mate quantification of urine albumin, expressed
on a scale from 0 to ⫹⫹⫹ or ⫹⫹⫹⫹. This is
Protein-Creatinine Ratio
2 analytes
treatment
confirmed by the following data obtained in our
1 g/L
laboratory: in 30 samples with ⫹ albumin by
means of dipstick, we found a protein concentra-
tion, measured by using benzetonium chloride,
Reduced preanalytic
that ranged from 100 to 1,600 mg/L (10 to 160
Requires only 1 spot
urine sample
errors
(60 to 333 mg/dL; mean, 1,445 ⫾ 665 mg/L
[144.5 ⫾ 66.5 mg/dL]); and in another 30 samples
with ⫹⫹⫹ albumin, protein concentration ranged
from 1,060 to 8,680 mg/L (106 to 868 mg/dL;
Requires detailed
contamination
Inconvenient for
preanalytic
Possibility of
collection
mg/dL]).
patients
Frequent
during
monitoring proteinuria
Averages the circadian
rhythm of protein
during treatment
Most accurate for
immunoglobulins
semiquantitative
proteinuria
monitoring
method
Protein-CreatinineRatioonaRandomUrineSample
Dipstick
esterase, nitrites)
countries
Low cost
24-hour protein excretion. However, it should be sensitivity of this test is low, whereas specificity
remembered that a normal protein-creatinine ra- is greater than 90%.
tio is sufficient to rule out the presence of patho-
logical proteinuria (which decreases the number Bile Pigments
of unnecessary 24-hour urine collections), With the introduction of liver enzyme measure-
whereas in the case of a protein-creatinine ratio ment in blood, detection of urinary urobilinogen
greater than the cutoff value, a full 24-hour and bilirubin has lost its clinical utility.
quantification is indicated. Moreover, correlation
between protein-creatinine ratio and 24-hour pro- Ketones
tein excretion may be not accurate at protein This dipstick is based on the reaction of nitro-
levels greater than 1g/L (⬎0.1 g/dL), and the prusside with acetoacetate and acetone. These
reliability of protein-creatinine ratio for monitor- are excreted into urine during diabetic acidosis,
ing proteinuria during treatment is still not proven. fasting, vomiting, or strenuous exercise.
Leukocyte Esterase
ADDITIONAL READING
This dipstick evaluates the presence of leuko-
1. Cheng J-T, Mohan S, Nasr SH, et al: Chyluria present-
cytes on the basis of indoxyl esterase activity ing as milky urine and nephritic range proteinuria. Kidney
released from lysed neutrophils and macro- Int 70:1518-1522, 2006
phages. This explains why, in urine with alkaline 2. Dorizzi RM, Caputo M: Measurement of urine relative
pH and/or low relative density, which favors the density using refractometer and reagent strips. Clin Chem
lysis of leukocytes, there frequently is a positive Lab Med 36:925-928, 1998
3. Lam MO: False hematuria due to bacteriuria. Arch
dipstick result, but negative microscopy find- Pathol 119:717-721, 1995
ings. Conversely, high relative density values 4. Bridgen ML, Edgell D, McPherson M, et al: High
decrease the sensitivity of this dipstick because incidence of significant urinary ascorbic acid concentration
of the prevention of leukocyte lysis. in a West Coast population–Implication for routine analysis.
False-negative results also occur in the pres- Clin Chem 38:426-431, 1992
5. National Kidney Foundation: K/DOQI Clinical Prac-
ence of high glucose or protein concentrations tice Guidelines for Chronic Kidney Disease: Evaluation,
(ⱖ20 g/L and ⱖ5 g/L [ⱖ2 g/dL and ⱖ0.5 g/dL], classification, and stratification. Am J Kidney Dis 39:S93-
respectively) or in the presence of cephalotine S102, 2002 (suppl 1)
and tetracycline (strong interference), cephalex- 6. Price CP, Newall R, Boyd JC: Use of protein:
ine (moderate interference), or tobramycin (mild creatinine ratio measurements on random urine samples for
prediction of significant proteinuria: A systematic review.
interference). Clin Chem 51:1577-1586, 2005
False-positive results are very rare (eg, when 7. Polkinghorne KR: Detection and measurement of
formaldehyde is used as urine preservative). Sen- urinary protein. Curr Opin Nephrol Hypertens 15:625-630,
sitivity varies from 76% to 94%, and specificity, 2006
from 68% to 81%.
The detection limit of dipstick is 20 ⫻ 106 MICROSCOPY
leukocytes/L. Methods
Nitrites Microscopy is an integral part of basic urinaly-
sis and adds irreplaceable information to the
This dipstick test shows the presence of bacte-
physicochemical investigation, especially when
ria that have the capability of reducing nitrates to
performed by a trained nephrologist. However,
nitrites because of nitrate reductase activity. This
reliable results can be achieved only with stan-
is present in most gram-negative uropathogenic
dardized methods for the handling of urine, one
bacteria, but is low or absent in others, such as
example of which is shown in Table 4.
Pseudomonas species, Staphylococcus albus, and
Enterococcus species. Notes
Test positivity also requires a diet rich in
nitrates (vegetables), which form the substrate Second Urine of the Morning
for nitrite production, and sufficient bladder incu- We prefer this urine to the first urine of the
bation time. Thus, it is not surprising that the morning (produced overnight) because pro-
Core Curriculum in Nephrology 1057
Table 4. Example of Standardization for Preparation identification of lipids and crystals with doubtful/
of Samples for Urine Microscopy unusual appearance.
Written instructions to patients for urine collection
Examination of the Sample
Collection in disposable containers of the second urine of
the morning after discarding the first few milliliters of We currently examine no fewer than 20 micro-
urine (midstream technique) scopic fields at original magnification ⫻160 in
Sample handling and analysis within 2-3 hours from different and random areas of the sample. Then,
collection
Centrifugation of a 10-mL aliquot of urine at 400g (2,000
we pass to original magnification ⫻400 for care-
rpm) for 10 minutes ful analysis of particles shown by the overview at
Removal by suction of 9.5 mL of supernatant urine low magnification. For such special conditions
Gentle, but thorough, resuspension with a pipette of the as isolated microscopic hematuria of unknown
sediment in the remaining 0.5 mL of urine origin, we always examine 50 microscopic fields
Transfer by pipette of 50 L of resuspended urine to a
slide
at original magnification ⫻160 to evaluate
Covering sample with a 24 ⫻ 32-mm coverslip whether erythrocyte casts are present.
Examination of all samples by a phase contrast
microscope at original magnifications ⫻160 and ⫻400 Match With Dipstick Results
Use of polarized light to identify doubtful lipids and For correct interpretation of the findings, both
crystals
Match of microscopic findings with dipstick for pH,
pH and specific gravity of the sample must be
specific gravity, hemoglobin, leukocyte esterase, and known. Alkaline pH and/or low specific gravity,
albumin especially less than 1.010, favor the lysis of
For routine work, cells expressed as lowest to highest erythrocytes and leukocytes, which can cause
number seen/high-power field, casts as number/low- false-negative results by means of microscopy.
power field, all the other elements on a scale from 0 to
⫹⫹⫹⫹
The knowledge of pH also is useful for the
For scientific work, cells expressed as total number correct identification of crystals (discussed later).
counted on 20 high-power fields The knowledge of albumin results is of help in
Note: This method is used in the authors’ laboratory. the evaluation of patients with a glomerular
disease.
ney diseases. From the clinical standpoint, it is Urinary tract infection and contamination of
useful to be able to distinguish the so-called urine from genital secretions are the most fre-
isomorphic erythrocytes, which are similar to quent conditions associated with leukocyturia
erythrocytes found in the bloodstream (Fig 1A), (and bacteriuria). However, this also is found in
from dysmorphic erythrocytes, which are charac- patients with acute or chronic interstitial nephri-
terized by irregular shapes and contours (Fig tis, proliferative glomerulonephritis, and urologi-
1B). The former are suggestive of hematuria of cal disorders.
urological origin, whereas the latter are typical of Eosinophils, once considered a marker of acute
patients with a glomerular disease. This distinc- allergic interstitial nephritis caused by antibiot-
tion is of special value for patients with isolated ics, are now regarded as nonspecific elements.
microscopic hematuria of unknown origin be- By use of the highly sensitive and specific Han-
cause it allows one to orientate the diagnosis sel stain, it was shown that eosinophiluria can be
toward a nephrological cause of hematuria, rather found in a wide spectrum of conditions, such as
than a urological one, which can spare the patient rapidly progressive glomerulonephritis, prostati-
inappropriate or invasive procedures. tis, chronic pyelonephritis, urinary schistosomia-
Unfortunately, the lack of unequivocal criteria sis, and renal cholesterol embolism.
for this type of analysis has hampered the diffu- Lymphocytes are seen as an early and reliable
sion of this test. marker of acute cellular rejection in renal allo-
In our laboratory, we consider hematuria to be graft recipients. However, their identification re-
glomerular when 40% or greater of erythrocytes quires cytological techniques, and today this
are dysmorphic and/or 5% or greater of erythro- approach is very rarely used in clinical practice.
cytes examined are acanthocytes (also known as
G1 cells). These are a subtype of dysmorphic Macrophages
erythrocytes that are easily identifiable because
of their peculiar appearance; namely, a ring- Macrophages are cells of variable size (15 to
shaped body with 1 or more protruding blebs of ⬎100 m) and appearance: fatty (the so-called
variable shape and size (Fig 1C). “oval fat bodies”; Fig 2A and B), phagocytic,
vacuolar, or granular (Fig 7 online). Recent
Leukocytes studies performed with monoclonal antibodies
Neutrophils are the leukocytes most fre- specific for macrophages showed that these
quently found in urine. They have a diameter of 7 cells can be found in urine of patients with
to 13 m and are easily identifiable because of nonselective proteinuria, active glomerulone-
their granular cytoplasm and lobulated nucleus phritis, or immunoglobulin A nephropathy.
(Fig 4 online). However, further investigation is necessary to
1060 Fogazzi, Verdesca, and Garigali
Hyaline Colorless, easily missed with bright field microscopy Normal subject and renal disease
Hyaline-granular Variable amounts of granules plunged in the colorless Normal subject and renal disease
matrix of the cast
Granular (finely and Fine granules caused by lysosomes containing Renal disease of whatever nature
coarsely granular) ultrafiltered proteins
Coarse granules caused by degenerated RTECs or
leukocytes entrapped within the cast
Waxy Large, with hard and indented contours and a “melted Renal insufficiency, either acute or
wax” appearance chronic
Fatty Containing various amounts of lipid droplets, rarely Marked proteinuria
cholesterol crystal Nephrotic syndrome
Erythrocytic Containing erythrocytes (from few to uncountable, Proliferative/necrotizing
sparse or packed), occasionally with a brownish hue GN Glomerular bleeding (of
particular value in patients with
isolated microscopic hematuria
of unknown origin)
Hemoglobin With a brownish hue; often with a granular appearance The same as the erythrocytic casts
caused by the degradation of erythrocytes Hemoglobinuria
Leukocytic Containing leukocytes Acute interstitial nephritis
Acute pyelonephritis
RTEC (epithelial) casts Containing RTECs Acute tubular necrosis
Acute interstitial nephritis
GN (especially of proliferative type)
Myoglobin Similar to hemoglobin casts Rhabdomyolysis
Bilirubin Yellow All conditions associated with
bilirubinuria
Containing Containing bacteria or yeasts Bacterial or fungal infection of the
microorganisms kidney
Containing crystals Containing uric acid, calcium oxalate, etc Crystalluria with/without renal
function impairment
Mixed Waxy-granular, fatty-granular, granular-erythrocytic, etc See waxy, granular, fatty,
erythrocytic casts
Abbreviations: GN, glomerulonephritis; RTEC, renal tubular epithelial cell.
Core Curriculum in Nephrology 1061
Sulfadiazine Birefringent “shocks” of wheat or “shells” with striations Isolated crystalluria, hematuria,
ARF, stones
Acyclovir Birefringent fine needles Isolated crystalluria, ARF
Indinavir Birefringent plate-like rectangles, star-like forms, Isolated crystalluria, stones, ARF
irregular plates
Piridoxylate Asymmetrical hexagons or rectangles with rounded Crystalluria and stones
extremities
Primidone Birefringent hexagons Isolated crystalluria, transient
hematuria
Felbamate Needles, cat-tail configuration Macroscopic hematuria, ARF
Amoxicillin Birefringent needles, shocks of wheat Isolated crystalluria, hematuria,
ARF
Ciprofloxacin Birefringent needles, sheaves, stars, fans, butterflies, etc Isolated crystalluria, ARF
Naftidrofuryl oxalate Birefringent monohydrate calcium oxalate ARF
Vitamin C Birefringent monohydrate calcium oxalate ARF
Orlistat (No better defined) calcium oxalate ARF
Abbreviation: ARF, acute renal failure.
ten that in rare cases, there may be an active renal Both these instruments, compared with manual
disease in the absence of nephritic sediment. microscopy, achieve acceptable results for eryth-
rocytes, leukocytes, squamous epithelial cells,
Urinary Tract Infection some types of crystals, bacteria, yeasts, and
False-positive results may occur as a conse- sperms. However, they do not recognize such
quence of urine contamination from genital secre- particles of nephrological importance as lipids
tions or bacterial overgrowth upon standing. and RTECs and give too many false-negative
False-negative results may be caused by misinter- results for casts (flow cytometry, 15% to 40%;
pretation of bacteria (especially with cocci) or digital imaging system, ⬃60%).
lysis of leukocytes, favored by alkaline pH and/or Today, these instruments are used in large
low specific gravity, or delayed urine sediment laboratories to screen large numbers of mostly
examination. normal samples in a short time. In our opinion,
In addition, nonspecific urinary abnormalities this approach is not adequate for renal patients,
can be found. In many instances, the urinary for whom manual microscopy coupled with a
findings can be nonspecific and not arranged in motivated and well-educated examiner repre-
one of the urinary profiles described (a few sents the gold standard.
hyaline or hyaline-granular casts with or without
mild erythrocyturia or leukocyturia, a few com- ADDITIONAL READING
mon crystals, a few superficial transitional cells, 1. Delanghe JR, Kouri TT, Huber AR, et al: The role of
etc). In such cases, the correct interpretation of automated urine particles flow cytometry in clinical practice.
urinary findings requires adequate clinical infor- Clin Chim Acta 301:1-18, 2000
mation and results of other diagnostic tests. 2. Linko S, Kouri TT, Toivonen E, et al: Analytical
performances of the Iris iQ200 automated urine microscopy
analyzer. Chim Clin Acta 372:54-64, 2006
ADDITIONAL READING
1. Gay C, Cochat P, Pellet H, et al: Le sédiment urinaire ACKNOWLEDGEMENTS
dans l’insuffisance rénale aiguë de l’enfant. Pediatrie 42:723-
727, 1987 Support: None.
2. Hebert LA, Dillon JJ, Middendorf DF, et al: Relation- Financial Disclosure: Dr Fogazzi is a consultant for A.
ship between appearance of urinary red blood cell/white Menarini Diagnostics, from which he receives honoraria.
blood cell casts and the onset of renal relapse in systemic
lupus erythemathosus. Am J Kidney Dis 26:432-438, 1995 SUPPLEMENTARY MATERIALS
3. Fujita T, Ohi H, Endo M, et al: Levels of red blood
cells in the urinary sediment reflect the degree of renal Figure S1: Isomorphic erythrocytes.
activity in Wegener’s granulomatosis. Clin Nephrol 50:284- Figure S2: Different types of dysmorphic erythrocytes.
288, 1998 Figure S3: Acanthocytes or G1 cells.
4. Fogazzi GB, Saglimbeni L, Banfi G, et al: Urinary Figure S4: Polymorphonuclear leukocytes with granular
sediment features in proliferative and non proliferative cytoplasm and lobated nucleus.
glomerular diseases. J Nephrol 18:703-710, 2005 Figure S5: “Oval fat bodies” or macrophages packed with
5. Verdesca S, Brambilla C, Garigali G, et al: How a lipid droplets.
motivated and skilful urine sediment examination can save Figure S6: Oval fat bodies under polarized light.
the kidneys. Nephrol Dial Transplant 22:1778-1781, 2007 Figure S7: A granular macrophage.
Figure S8: Proximal renal tubular cells.
AUTOMATED ANALYSIS OF THE Figure S9: Deep urothelial cells.
Figure S10: A clump of superficial transitional cells.
URINE SEDIMENT Figure S11: Squamous cells.
In recent years, instruments for automated Figure S12: A colorless hyaline cast with Tamm-Horsfall
glycoprotein fibrils.
analysis of urinary sediments have been put on Figure S13: A hyaline-granular cast.
the market, obtaining widespread diffusion. Figure S14: A finely granular cast.
One instrument is based on flow cytometry, Figure S15: A waxy cast with typical “melted wax”
and the other on digital imaging software. Flow appearance.
cytometry supplies results as both “scatter- Figure S16: A fatty cast with packed lipid droplets.
Figure S17: A fatty cast under polarized light.
grams” and numeric data. The other instrument Figure S18: An erythrocyte cast.
supplies results as both black and white images Figure S19: A renal tubular epithelial cell cast with large
and numeric data. nucleus.
Core Curriculum in Nephrology 1067
Figure S20: A hemoglobin cast. Figure S27: Two triple phosphate crystals.
Figure S21: A bilirubin cast. Figure S28: A cholesterol crystal.
Figure S22: An aggregate of rhomboidal uric acid crystal Figure S29: Cystine crystals.
under polarized light. Figure S30: Amoxicillin crystals under polarized light.
Figure S23: Birefringent amorphous urates. Figure S31: Birefringent star-like crystals of ciprofloxacin.
Figure S24: Ovoidal monohydrated calcium oxalate crys- Figure S32: An egg of Schistosoma hematobium with
tals under polarized light. typical terminal spike.
Figure S25: Bihydrated calcium oxalate crystals. Note: The supplementary material accompanying this
Figure S26: A star-like calcium phosphate crystal birefrin- article (doi:10.1053/j.ajkd.2007.11.039) is available at
gent under polarized light. www.ajkd.org.