Casts in Urine

Urinary casts are cylindrical aggregation of particles that form in the

distal nephron, dislodge and pass into the urine. In urine analysis they
indicate kidney disease. They form via precipitation of Tamm-Horsfall
mucoprotein which is secreted by renal tubule cells.
There are 10 types of casts.

Causes of Pyuria

Acellular Cast Cellular Cast

1. Hyaline cast 7. Red cell cast
2. Granular cast 8. White cell (pus) cast
3. Waxy cast 9. Epithelial cell cast
4. Fatty cast 10. Bacterial casts
5. Pigment cast
6. Crystals cast

Hyaline Casts
❖ Hyaline casts are the most frequently occurring casts in urine.
Hyaline casts are seen in even the mildest renal disease.
❖ Increased numbers are seen with exercise, heat exposure,
dehydration, fever, congestive heart failure and diuretic therapy.
❖ They are colorless, homogeneous, transparent and usually have
rounded ends. The ends may be tapered also. They do not contain
any cells.
❖ They are variable in length, occasionally curved, convoluted and of
variable breadth. Generally hyaline casts have parallel sides with
clear margins and blunted ends.
❖ They consist of coagulated protein (Tamm-Horsfall mucoprotein
secreted from tubular cells) material. Few casts may be seen in
normal urine.
❖ Hyaline casts are best seen by reducing the light on the microscope
or lowering the condenser.
 Causes of hyaline casts in urine
1. After exercise 5. Damage to the glomerular capillary
2. Old age 6. Nephritis
3. Hypertension 7. Nephrosis
4. Fever 8. Nephrosclerosis
❖ Hyaline casts are stained yellow in jaundice.
❖ These casts are broad in the late stage of glomerulonephritis known
as renal failure casts.

Red Cell Casts

➢ Red cell casts are formed by the conglutination of red cells within
the tubular lumen.
➢ They are formed in the distal nephron
➢ Red cell casts indicate renal haematuria.
➢ Red cell casts may appear brown to almost colorless and usually
diagnostic of glomerular disease.
➢ These casts are better visualized with phase contrast microscopy or
with supra-vital staining, in which case erythrocytes are colorless or
lavender in a pink matrix.
➢ Red cell casts are yellow to orange in color.
➢
Causes of red cell casts in urine
1. Acute glomerulonephritis 5. Renal infarction
2. Polyarteritis nodosa 6. IgA nephropathy
3. Subacute bacterial endocarditis 7. Lupus nephritis
4. Malignant hypertension 8. Severe pyelonephritis

Granular Casts
★ Granular casts can result either from the breakdown of cellular casts
or the inclusion of aggregates of plasma proteins (e.g. albumin) or
immunoglobulin light chains.
 ★ The casts are closely packed with granules, which may be coarse or
fine. Accordingly, they are designed as coarse granular casts or fine
granular casts.
★ These are rather short casts, pale and yellow with rounded ends.
★ It is suggested that granules arise from degeneration of the
epithelial cells. When epithelial cells are retained for sometimes in
tubules, the cells degenerate to form coarse granules. Fine salt
precipitates and lysosomes may also be granular components.
★ Broad granular casts (renal failure casts) may occur in advanced
stages of various types of glomerulonephritis.

Causes of granular casts

1. Chronic glomerulonephritis (broad granular cast) 6. Jaundice (yellow gran
2. Chronic pyelonephritis 7. Viral infections
3. Benign hypertension 8. Renal papillary necro
granular casts)
4. Chronic lead poisoning 9. Hyperparathyroidism
5. Black water fever (brown granular cast) 10. Extreme stress or s

Pus Cell Casts

Pus cell casts are refractile, exhibit granules, and frequency multilobed
nuclei will be visible unless disintegration has begun. They are formed by
aggregation of pus cells/leukocytes in renal tubules. They indicate:
➔ Suppurative lesions in kidneys such as pyelonephritis, glomerular
disease owing to the chemotactic effect of complement.
➔ Interstitial nephritis
➔ Lupus nephritis
➔ Nephrotic syndrome

Hyaline cast may contain few leukocytes

● Indicative of inflammation or infection
● Pyelonephritis
● Acute allergic interstitial nephritis
● Nephritic syndrome
 ● Post-streptococcal glomerulonephritis

Epithelial Cell Casts

⇝ Epithelial casts are formed by the conglutination of tubular
epithelial cells within the nephron.
⇝ Epithelial casts are usually swollen, and are yellowish or brownish in
color
⇝ Hyaline casts may also take up a large number of desquamated
epithelial cells.
⇝ A drop of 10% acetic acid, when added to the deposit, makes the cast
cells more distinct.
⇝ Epithelial casts are rare but pathological.
⇝ Their presence indicates tubular damage
⇝ Broad epithelial casts signify severe tubular damage and suggest the
onset of uremia
Causes of epithelial casts
➷ Toxic nephrosis
➷ Toxemia of pregnancy
➷ Jaundice
➷ Severe malaria
➷ Acute tubular necrosis
➷ Acute allograft rejection
➷ General infections
➷ Exposure to variety of drugs
➷ Amyloid nephrosis
➷ Viral disease (cytomegalovirus disease)
➷ Heavy Metal poisoning

Crystal Casts
➼ Crystal casts are crystalized urinary solutes , such as oxalates,
urates, or sulphonamides, which may become enmeshed within a
hyaline cast during its formation.
➼ The clinical significance of this occurrence is not felt to be great.
➼ Haematuria, possibly related to tubular damage, regularly
 accompanies crystal casts.

Fatty Casts
♥ Fatty acids are formed by the breakdown of lipid rich epithelial cells.
♥ These are hyaline casts with fat globule inclusions.
♥ Fatty casts have globules of fat adherent to them, which may be
recognized by staining with a drop of Sudan Ⅲ solution.
♥ These are very refractile yellowish casts, the edges are intended and
vary distinct and the ends are rounded
♥ Fatty casts are soluble in ether but not in acetic acid.
♥ Fatty casts are always pathological.
Fatty casts are present in various disorders including:
❦ Chronic parenchymatous nephritis
❦ Nephrotic syndrome
❦ Diabetic or lupus nephropathy
❦ Acute tubular necrosis

Waxy Casts
‫ ۝‬Waxy casts are, clear, yellowish or bluish, broader than the other
varieties, dull and opaque in appearance with clefts and broken off
square ends as if they are brittle.
‫ ۝‬They are usually pathogenic.
‫ ۝‬They are seen in advanced nephritis indicating unfavorable
prognosis.
‫۝‬They are in plenty in amyloid kidney.
‫ ۝‬Waxy casts are associated with tubular inflammation and
degeneration.
‫۝‬They are observed most frequently in patients with chronic renal
failure.

Pigment Casts
☻Pigment casts are formed by the adhesion of metabolic breakdown
products of drug pigments.
☻Pigment casts are hyaline, may be slightly granular and coloured
greenish brown to dark brown.
☻Pigments include those produced endogenously such as:
 ☺ Hemoglobin in haemolytic anemia and transfusion reaction.
☺ Myoglobin in rhabdomyolysis : Myoglobin casts are seen in
crushing injury, massive muscle necrosis, and
idiopathic myoglobinuria. These casts are red brown in color
☺ Bilirubin in liver disease: Bilirubin casts are deep yellow
brown in colour and are seen in obstructive jaundice.
☺ Lower nephron nephrosis: Hemoglobin and myoglobin cast
formation play significant role in the genesis of
Oliguria in acute renal failure following crushing injury etc.

Bacterial Casts
True bacterial casts are seen in suppurative renal disease. However,
bacteria may imbibed hyaline or granular casts.

Mixed Cellular Casts

Two distinct casts may be present within a single cast.
This has been referred to as a mixed cast (for example
leukocyte/renal, erythrocyte/leukocyte, and eosinophil/renal).

CELLS IN URINE SEDIMENT

SMALL ROUND OR POLYHEDRAL CELLS

♣ These cells come from deeper layers of the urinary tract.
♣ In chronic passive congestion, renal infarct and haemochromatosis,
the cells may contain yellow granules of altered blood pigment.
♣ In glomerulonephritis, the cells are fatty.

PARABASAL CELLS
♦ Squamous epithelial cells are immature epithelial squamous cells.
♦ They are commonly seen in urine specimens from post-menopausal
women with atropic vaginitis resulting from decreased oestrogen
(oestradiol levels).

TRANSITIONAL EPITHELIAL CELLS

Transitional epithelial cells originate from the renal pelvis, ureters,
urinary bladder and/or urethra
♠ Their size and shape depends on the origin in the mucosa.
♠ Most often they are round or polygonal; less commonly
pear-shaped.
♠ They are generally somewhat smaller and smoother in outline than
squamous cells and WBCs.
♠ Their size ranges from 40-200 μm
♠ In clearly collected normal specimens, transitional cells are few
(>2/HPF), but are more frequent in the elderly population.
♠ However, the presence of transitional sheets (brick wall appearance)
is sometimes associated with transitional cell carcinoma.

RENAL TUBULAR CELLS

❆ Renal tubular cells are originally cubic in shape, but once exfoliated,
they adopt a rounded shape.
❆ These cells are slightly larger than leukocytes (10-14μm) with lightly
granular cytoplasm.
❆ The nucleus is round, well defined and usually centric. The
cytoplasm often shows a perinuclear halo when stained.
❆ Renal epithelial cells from proximal or distal convoluted tubules
necrosis and toxically due to certain drugs and metals.
❆ The increased number of collecting duct epithelial cells is seen in
acute glomerulonephritis.

LIPID IN RENAL TUBULAR CELLS

❅ Some renal epithelial cells contain fat bodies in their cytoplasm.
❅ These fat containing cells may be associated with fat globules of
various sizes.
❅ The presence of any or all of these forms are accompanied by
marked proteinuria is characteristic of nephrotic syndrome.

HAEMOSIDERIN IN EPITHELIAL CELLS

Occasionally renal epithelial cells may also contain haemosiderin
pigment or inclusion bodies of viruses such as cytomegalovirus.

MELANIN
Melanin granules are absorbed into the tubular cells in cases of
melanuria.
 CRYSTALS IN URINE
1. CRYSTALS FOUND IN NORMAL ACID URINE
Calcium Oxalate Crystals
☃ They are also colorless and have an envelope, octahedron or
dumbbell-shape.

Various types of crystals in urine

Crystals in acidic urine Crystals in alkaline urine

Amorphous urates Ammonium biurate
Calcium oxalate Magnesium
Crystalline Phosphate (triple phosphate)
Leucine Calcium carbonate
Crystalline urates Stellar phosphates
Crystalline uric acid
Uric acid

☃ Ovoid forms may occur. Their size is variable.

☃ They are found most frequently in acid urine (pH 6), but may occur
in neutral or alkaline urine as well.
☃ They are insoluble in acetic acid, but soluble in hcl acid. They are
associated with food like tomatoes, rhubarb, and spinach.
☃ If present in large numbers are of some clinical importance,
indicating the possible formation of a calculus.
☃ Oxalate crystals in large numbers may reflect severe chronic renal
disease or ethylene glycol or methoxyflurane toxicity.

Amorphous Urates
〆 Calcium, magnesium, sodium, and potassium urates are amorphous.
〆 Amorphous urates will precipitate upon standing in concentrated
urine of a slightly acidic pH.
〆 Microscopically amorphous material is yellow brown small granules
that can form clumps and adhere to top fibres and mucous threads.
Crystalline Urates
✸ Sodium, potassium, and ammonium urates are crystalline.
 ✸ These biurates and acid urates from small brown spheres or
colorless needles in slightly acidic urine.

Ammonium Urate Crystals

✴ Ammonium urates may occur in acid neutral or alkaline urine.
✴ Usually colored due to pigments.
✴ Ammonium urate occurs ordinarily in the form of the so-called
‘thorn apple’ , or ox horn crystals.

Sodium Urate Crystals

✶ Occur in acidic urine.
✶ Sodium urate, when crystalline, occurs as fan-shaped clusters or
prismatic needles
✶ It may have a stellar appearance or star-shaped appearance.

Crystalline Uric Acid Crystals

⍣ Appears in acid urine.
⍣ Uric acid crystals may appear as yellow to brown rhombic or
hexagonal plates, needles, or rosettes, prisms, oval form with
pointed ends (lemon-shaped).
⍣ Rarely they are colorless and hexagonal-shaped, resembling
crystalline.
⍣ These are dissolved on warming at 60⁰C or addition of sodium
hydroxide.
⍣ Do not dissolve in acetic acid.

Causes of uric acid crystals and urates

1. Increased nucleoprotein turnover, especially during chemotherapy
of leukaemias and lymphoma.
2. Lesch-Nyhan syndrome.
3. Urate nephropathy in gout.

2. CRYSTALS FOUND IN NORMAL ALKALINE URINE

Triple Phosphate Crystals (Crystalline phosphates)
✌ They occur usually in alkaline urine and are seen in the form of
rhomboid prisms of characteristic appearance, so-called ‘coffin lid’
shape, although they may be present into bizarre shapes.
✌ They may be present fern like or feathery. Occasionally, they may
closely resemble the large envelope forms of calcium oxalate, but
 may be distinguished from them by their ready solubility in acetic
acid.
✌ The most common phosphates are seen amorphous phosphates, and
the ammonium magnesium phosphates.
✌ They may occur in urinary tract infection with urea splitting
bacteria, in drug-induced alkalinity of urine or when urine becomes
contaminated with bacteria after being voided.

Stellar Phosphate (Calcium Hydrogen Phosphates)

✪ They are found in alkaline urine and in acid urine with pH between 6
to 7. They are less frequently than triple phosphate crystals.
✪ The crystals are colorless. They may have different shapes.
1. Rosette or star-shaped crystals
2. Irregular plates
3. Flakes

Magnesium Phosphates
‫ ؞‬They occur in alkalined and weakly acidic urine.
‫ ؞‬They are colorless, rhombic plates and are much less common than
triple or stellar phosphate crystals.

Amorphous Phosphates
✦ They occur in alkaline urine as colorless fine granules or spheres.
✦ Phosphates crystalline or amorphous dissolve in dilute acetic acid,
hcl acid, or nitric acid.
✦ Urine phosphates, amorphous or crystalline dissolve in dilute acetic
acid.

Calcium Carbonate
☪ These uncommon crystals are small and colorless, with dumbbell or
spherical shapes.
☪ They may form pairs, fours, or clumps.

Tyrosine
✿ Tyrosine crystals occur rarely in the urine.
✿ When they do occur it is usually in the urine of patients with acute
yellow atrophy cirrhosis of the liver. Phosphorus poisoning or in
leukaemia .
 ✿ Tyrosine crystals are usually seen as fine brownish needles, either
isolated or as rosettes.
✿ Tyrosine crystals are insoluble in ether and acetone and soluble in
alkali. Crystals of amino acids leucine and tyrosine are very rarely
seen in urine rediments.
✿ These crystals can be seen in some hereditary diseases like
tyrosinosis and Maple syrup disease.

Leucine
⚘ Leucine crystals are seen as yellow spheres with concentric acid and
radial striae.
⚘ These crystals can sometimes be mistaken for cells, with the center
resembling the nucleus.
⚘ Under polarized, leucine crystals transmit a ‘maltese cross’
interference pattern.
⚘ Leucine when crystalline occurs in spherical masses, which show
characteristic radial and concentric striations, and are highly
refractive.
⚘ Leucine crystals are seen occasionally in patients with severe liver
disease.

Cystine crystals
☀ Cystine crystals are seen as flat colorless hexagonal plates.
☀ They are aggregates in layers, and their formation is favored in
acidic urine.
☀ The crystals are soluble in 30% by volume of Hcl acid.
☀ Cystine crystalluria or urolithiasis is an indication of cystinuria,
which is an inborn error of metabolism involving, defective renal
tubular reabsorption of certain amino acids including cystine.

Sulphonamide (sulphadiazine) Crystals

✍ Sulphonamide crystals are typically yellow in color and often
resemble uric acid crystals. However, sulfa crystals are easily
distinguished from urine acid by confirmatory tests.
✍ Sulfa crystals are readily soluble in acetone and exhibit a positive
dextrin. These crystals may be seen in urine of acid pH.
✍ Sulfadiazine crystals are a common finding with administration of
trimethoprim sulphadiazine.
 ✍ They are often seen as ‘shocks of wheat’ or radially spherules. When
the crystals get deposited in the urinary tract they can cause
haematuria and other complications.
Cholesterol
☤ Cholesterol crystallizes as thin rectangular plates with one
(sometimes two) of the corners having a square notch.
☤ They are insoluble in acids and alkalis but soluble in ether, ethanol
and chloroform.
☤ The cause of the presence of crystallized cholesterol is obscure.
☤ These crystals are seen in degenerative renal diseases.
☤ They are seen when a lymphatic vessel has ruptured into the renal
pelvis.

Bilirubin Crystals
☘ Bilirubin crystals are abnormal crystals in urine.
☘ They are in the form of yellow brown needles or granules. They are
attached to the surface of the cells.
☘ Bilirubin crystals are seen in several hepatic disorders.
☘ The appearance of bilirubin crystals should be accompanied by a
positive biochemical test for bilirubin.

Xanthine Crystals
Xanthine crystals are usually in the form of amorphous crystals.

Haematoidin
✐ Haematoidin crystals may occur in the urine of persons with various
liver diseases.
✐ They may be seen as tufts of small needles, or as small yellow red
plates.

Bacteria
❣ The finding of bacteria in freshly passed uncentrifuged urine
indicates a urinary infection. The bacteria, usually rods, but
sometimes cocci or streptococci can be seen with 40X objective.
❣ Bacteria is considered significant when there is presence of 10000
or more bacteria per ml of urine.
❣ Sediment : >20 or more bacteria per high power field may indicate a
urinary tract infection.
 ❣ Acid fast bacteria may be seen in urine sediment. The presence of
tubercle bacilli in urine must be substantiated by culture or
polymerase chain reaction.

Spermatozoa
Their head (5 μm) and long thread-like tail (50 μm) can easily recognise
spermatozoa. They may be motile in fresh urine.
Spermatozoa may be present in urine in the following conditions:
☄ Spermatozoa are often found in urine after sexual intercourse (both
men and women) or after ejaculation.
☄ However, all the conditions are associated with spermatorrhoea
(involuntary discharge of semen without orgasm) can cause the
presence of spermatozoa in the urine. Due to their unique shape,
spermatozoa can easily be identified in the urine.
☄ Nocturnal emission
☄ In the urine of men after epileptic convulsion.

Yeast Cells and Fungi

☂ Yeast cells are contaminated or represent a true yeast infection.
☂ They are different to distinguish from red cells and amorphous
crystals but are distinguished by their tendency to bud.
☂ These appear in urine as round or oval bodies of various sizes (5-12
μm).
☂ These are not soluble in acetic acid. Most often they are Candida,
which may colonize bladder, urethra or vagina.
☂ The threads of mycelium are longer and thicker than bacteria.
☂ They can be seen in the urine of women with vaginal candidates, and
occasionally in specimens from diabetes.

PARASITES IN URINE
Following parasites are present in urine:
1. Ova of Schistosoma haematobium
2. Trichomonas vaginalis
3. Microfilaria of Wuchereria bancrofti
4. Larva of strongyloides stercoralis
5. Ascaris lumbricoides
6. If there is Echinococcus disease of the kidney: small cysts or
hooklets from the cysts may be passed in urine.
 7. Egg of Enterobius vermicularis
8. Entamoeba histolytica

Ova of Schistosoma haematobium

☁ Haematoidin crystals may occur in the urine of persons with various
liver diseases.
☁ They may be seen as tufts of small needles, or as small yellowish red
plates.
☁ Size :110-150 μm
☁ Shape: Oval with one rounded pole
☁ Spine: Terminal and situated in the other pole
☁ Shell: Smooth, very thin
☁ Content: A well-formed broad ciliated embryo surrounded by a
membrane
☁ Color: Grey to pale yellow

Trichomonas vaginalis
♬ Trichomonas vaginalis is a leaf-shaped, globular, mobile flagellate
that measures about 8-30μm long with a nucleus near the rounded
anterior pole, and the axostyle.
♬ Its locomotive organs include four anterior flagella and an
undulating membrane.
♬ Alive trichomonas vaginalis can readily be identified due to mobility
of the flagella and the rapid and irregular movements of the body
across the microscopic field.
♬ Trichomonas is sometimes found in cases of urethritis,more
common among the females.
♬ In women genital contamination of urine may also be responsible for
the presence of trichomonas vaginalis in urine.

Microfilaria
♫ In chyluria, the centrifuged deposit may contain microfilaria. This
happens when a urogenital lymphatic vessel ruptures.
♫ The microfilariae are large, motile, and sheathed.
♫ The microfilariae of Onchocerca volvulus may be found in the urine
in onchocerciasis, especially in heavy inspections.
♫ The larvae are large (280-300 ⋊ 7 μm ), unsheathed, with slightly
enlarged head end and a tail which is sharply pointed and contains
 no nuclei.

ENTEROBIUS VERMICULARIS

Occasionally the eggs of Enterobius vermicularis are found in urine,

especially from young girls when the eggs are washed off the external
genitalia when the urine is passed.
Contaminants, which can be found in urine include cotton fibres,
starch granules, oil droplets, pollen grains, moulds; single celled called
plants, and debris from dirty slides or containers.

Viral Inclusion Cells

Viral inclusion bodies are seen in:
1. Herpetic infections: Syncytial giant cells containing eosinophilic
intranuclear inclusions.
2. Cytomegalovirus infection: The affected cells are enlarged and
contain basophilic intranuclear inclusion.
3. Polyomavirus infection on dense basophilic homogenous
intranuclear inclusion that often completely fill the nucleus .

Urine Cytology
⌚ For cytological evaluation of kidney and bladder, three morning
samples of urine (each of 50-100ml) obtained on consecutive days

⌚
are recommended.
Centrifuge the urine for 10 minutes and place one or drops of
sediment on a glass slide, spread the material and fix immediately.

⌚
Catheterized samples are also acceptable.
Malignant tumour cells exfoliated from the renal pelvis, ureter,

⌚
bladder wall, and urethra are identified using cytological techniques.
Myeloma cells may be present in urine.

AUTOMATION IN URINALYSIS
Autoanalyzer
Intended use: Twelve patch strip for the quantitative determination of
specific gravity, pH, leukocytes, nitrite, protein, glucose, ketone bodies,
urobilinogen, bilirubin, blood microalbumin, and creatinine in urine.
 Urine test strips are used to measure certain constituents in urine
which are significant of renal, urinary, hepatic and metabolic disorders.

Precautions and warnings

〠 For in vivo diagnostic use
〠 Exercise the precautions required for handling all laboratory
reagents
〠 Disposal of all waste materials should be in accordance with local
guidelines.
〠 The stopper of the test strip vial contains a non-toxic silicate-based
desiccant which must not be removed. If ingested by accident, drink
large quantities of water.
〠 Reagents handling: Ready for use

Storage and stability: Store the package at 2-30⁰C.

The test strips are stable up to the expiration date specified on
the box, when stored in the original container. Do not use the test strip
after the specified expiratory date.
Tightly recap the container immediately after removing a test strip.

⚡
Specimen Collection and Preparation

⚡
Use fresh urine that has not been centrifuged .
The urine specimen should not stand for more than 2 hours

⚡
before testing. In case of longer standing, mix before use.

⚡
Use only clean, well-rinsed vessels to collect urine.
False positive readings for blood and glucose can result from
residues of strongly oxidizing disinfectants in the specimen

⚡
collection vessel.
Do not expose urine specimens to sunlight as this induces
oxidation of bilirubin and urobilinogen and hence leads to artificially
low results for these two parameters.
Assay procedure
߷ Thoroughly mix the urine sample.
߷ Take a test strip out of the container. Close the container again with the
original desiccant stopper immediately after the removal of the strip.
This is important as otherwise the test areas may become discolored due
to moisture and incorrect results may be obtained
߷ Briefly (about 1 second) dip the test strip into the urine making sure all
the test areas are moistened.