Nephrol Dial Transplant (1996) 11: 379-387

Nephrology
Dialysis
Educational Course Transplantation

CrystaUuria: a neglected aspect of urinary sediment analysis

G. B. Fogazzi
Divisione di Nefrologia e Dialisi, Ospedale Maggiore, IRCCS, Milan, Italy

Abstract was introduced into clinical practice, many of the

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crystals known nowadays had already been identified,
Crystalluria is a frequent finding in the routine exam- including those of cystine which were first described in
ination of urine sediments. In most instances the 1810 by William H. Wollaston (1766-1828). In 1844,
precipitation of crystals of calcium oxalate, uric acid, when the first book on urinary deposits was published
triple phosphate, calcium phosphate and amorphous [3], crystals still represented the main elements of the
phosphates or urates is caused by transient supersat- urine sediment, as demonstrated by the fact that six
uration of the urine, ingestion of foods, or by changes chapters of that book were devoted to crystals and
of urine temperature and/or pH which occur upon only one to 'non crystalline organic deposits', whose
standing after micturition. In a minority of cases, length was only about one-third of the overall coverage
however, crystalluria is associated with pathological given to crystals. Interestingly, polarizing light and
conditions such as urolithiasis, acute uric acid nephro- chemical reagents added to urine samples on the stage
pathy, ethylene glycol poisoning, hypereosinophilic of the microscope were already in use at that time to
syndrome. In addition, crystalluria can be due to drugs identify crystals. By 1880 the classification of urinary
such as sulphadiazine, acyclovir, triamterene, piridox- crystals was similar to that which we know currently
ylate, primidone, which under the influence of various [4], the crystals of leucine and tyrosine having been
factors can crystallize within the tubular lumina and described by Theodor F. Frerichs (1819-1885) in 1854,
cause renal damage. In all these instances the study of and those of cholesterol by Lionel S. Beale (1828-1906)
crystalluria is diagnostically useful and is also import- in 1869.
ant to follow the course of the disease. However, a This paper describes the main types of urinary
proper methodological approach is necessary. This crystals as can be identified by conventional procedures
includes the handling of freshly voided urine, the and microscopy, as well as the nephrological disorders
knowledge of the urinary pH, and the use of a contrast in which the study of crystalluria is of importance.
phase microscope equipped with polarizing filters.
How to identify the urinary crystals
Introduction There are several types of urinary crystals (Table 1).
Since each type has a wide spectrum of possible
Crystals, seen as 'a heap of rhomboical bricks', were morphological appearances [5], a proper methodologi-
the first element described when urine was investiga- cal approach is necessary to identify them.
ted for the first time with a microscope in 1630 by First of all, the knowledge of the urinary pH is an
the French scholar Fabricius Nicolaus De Peiresc important prerequisite for the identification of crystals
(1580-1637) [1], and then were the first element of the as some crystals tend to precipitate in acidic urine,
urinary sediment to be shown in a figure as contained while others in an alkaline milieu. As shown in Table 1,
in Robert Hooke's 'Micrographia', published in 1665 uric acid crystals and urates are found exclusively in
(Figure 1) [2]. Crystals were the only known micro- acidic urine (pH< 5.4-5.8), while those of amorphous
scopic element of the urine for the whole 18th century, phosphates, triple phosphate and calcium phosphate
during the earlier part of which they attracted the are observed in urine with pH of 6.2 > 7.0. Calcium
attention of the great Hermann Boerhaave (1668— oxalate and cholesterol crystals on the other hand can
1734), who carried out experiments to evaluate be found in a wider pH range (< 5.4-6.7,) although
whether or not urine of the normal subjects contained they tend to be more frequent in acidic urine.
crystals [1]. In the late 1830s, when urine microscopy Crystals can precipitate while the urine is still in the
urinary system or after micturition when changes in
Correspondence and offprint requests to: Giovanni B. Fogazzi MD,
temperature and/or pH can occur upon standing. For
Divisione di Nefrologia e Dialisi, Ospedale Maggiore, IRCCS, Via instance, massive precipitation of urates or phosphates
Commenda 15, 20122 Milan, Italy. can occur if the urine is stored at 4°C, and triple

© 1996 European Dialysis and Transplant Association-European Renal Association

380 G. B. Fogazzi

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Fig.

Table 1. Number of positive samples, pH and polarization features of the crystals found in the 200 urine samples from December 1992 to
December 1994 in the Division of Nephrology and Dialysis of Ospedale Maggiore of Milano

Crystal Number pH features Birefringence

Range <5.8 (%) > 7.0 (%)

Ca-oxalate dihydrate 67 < 5.4-6.7 82 25

Uric acid 36 < 5.4-5.8 100 — 100
Amorphous phosphates 27 6.2->7.0 — 78 —
Triple phosphate 25 6.2->7.0 — 73 100
Ca-oxalate monohydrate 18 < 5.4-6.4 89 — 100
Cholesterol 15 < 5.4-6.7 73 ,— 27
Amorphous urates 7 < 5.4-5.8 100 — 100
Ca-phosphate plates 3 6.7->7.0 — 67 —
Ca-phosphate crystals 2 7.0 — 100 100

Crystals identified by phase-contrast microscopy and polarized light. pH measured by Dipstix. Urine centrifuged and analysed at room
temperature.

phosphate crystals can precipitate from a progressive
increase in pH caused by continuous multiplication of
urea-splitting bacteria after voiding. Thus it is import-
ant that the urine is handled as soon as possible and
at a temperature similar to that of the body. This is
particularly important for the study of crystalluria in
stone formers [6], although in this context urine stored
at room temperature or at 4°C for several hours is
used as well to study the latent phase of supersat-
uration [7,8].
The phase-contrast microscope, which represents the
state of the art in urine microscopy at present, is better
than bright-field microscopy in study of crystals, especi-
ally when these are small and colourless. It must be
equipped with polarizing filters, which allow differen-
tiation of birefringent crystals, which polarize light,
from non-birefringent crystals, which do not. The
knowledge of the polarizing features of crystals is
useful to distinguish: (1) crystals that are different in
composition but similar or identical in morphology;
for instance, amorphous urates polarize light while
phosphates do not (Table 1); (2) crystals from contam-
inants such as starch particles, which under polarized
light appear as 'pseudo Maltese crosses'; (3) hexagonal
crystals of uric acid from those of cystine. In general,
while the former polarize into many nice colours the
latter have a colourless birefringence [9].
Testing the solubility features of crystals is an addi-
tional means to identify them in doubtful cases. This
is done by adding to the sample on the stage of the
microscope, or to the tube containing the sediment,
few drops of a chemical reagent which is known to
dissolve the crystals under investigation. If the crystals
do not dissolve, they must then belong to another
category of crystal. Calcium oxalate is soluble in
hydrochloric acid and sodium hydroxide, while uric
Crystalluria: a neglected aspect of urinary sediment analysis
acid is soluble in alkali (and by heating.) Triple phos-
phate and calcium phosphate are soluble in hydro-
chloric acid and acetic acid [5].
However, one must be aware of the limitations with
these procedures, as even common crystals at times
cannot be identified with certainty due to possible
occurrences of unusual morphologies. For these cases
more sophisticated techniques are available such as
petrographic microscopy [10], scanning electron-
microscopy [11], infrared microscopy [12], or spectro-
photometry, which, however, are available only in
specialized laboratories.
The main types of urinary crystals
The most common urinary crystals are shown in
Table 1.
Calcium oxalate crystals (Figure 2)
There are two types of calcium oxalate crystals, the
dihydrate (or Wedellite) and the monohydrate (or
Whewellite), which are frequently found together in
the same sample. The former have mostly a typical
Fig. 2. Clockwise from top left: Typical bipyramidal calcium oxalate
dihydrate crystals (interference-contrast, 640 x). Ovoid monohydrate
calcium oxalate crystals (phase-contrast, 640 x). Rhomboid uric
acid crystals (phase-contrast, 400 x). Uric acid crystals under polar-
ized light (250 x). (From ref. 5, with permission).
381
bipyramidal shape, while the latter are more pleiomor-
phichic [13], although the ovoid shape is the most
frequent. Bipyramidal crystals are birefringent only
when large or in aggregates, but even then birefringence
is usually not intense. The monohydrates, however,
are always strongly birefringent (Table 1). Calcium
oxalate may be found in normal subjects, often as a
consequence of ingestion of foods like chocolate, beet-
root, peanuts, rhubarb, spinach, etc. [14], in stone
formers (Table 2), in patients with hyperoxaluria, or
after ethylene glycol poisoning (see 'Crystalluria and
acute renal failure').
Uric acid crystals (Figure 2)
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These are very pleiomorphic too, but the rhomboidal
shape is the most frequent. Distinctive morphological
features are the amber colour and the constant poly-
chromatic birefringence. These crystals can be found
both in normal subjects as well as in stone formers
(Table 2). Moreover, they can be found, alone or with
amorphous urates in patients with increased purine
metabolism (see 'Crystalluria and acute renal failure').
Amorphous phosphates (Figure 3)
These are tiny, colourless or dark granules which can
be either isolated or in clumps. Only the knowledge of
urinary pH and birefringence allow one to differentiate
them from amorphous urates (Table 1). Amorphous
phosphates are frequently found in association with
calcium phosphate crystals [11].
Triple phosphate crystals (Figure 3)
The typical shape is that of prisms ('coffin lid'), which
are always strongly birefringent (Table 1). Triple phos-
phate crystals are typical of infected urine, especially
that caused by urea-splitting bacteria. For this reason
they are frequently found also in patients with in-
fected calculi.
Calcium phosphate (Figure 3)
Crystals are pleiomorphic, often appearing as bire-
fringent stars or needles, occurring in isolation or
in clumps. Plates are granular and non-birefringent.
Calcium phosphate crystals were the most frequent
crystals in both normals and stone formers in the study
of Werness et al. [10]; however, this finding was not
confirmed by others (Table 2).
Cholesterol crystals (Figure 4)
These are transparent plates with well-defined edges
and corners, which polarize light inconstantly
382 G. B. Fogazzi
Table 2. Prevalence and type of crystalluria in normal subjects (N) and stone formers (SF) in fresh urine

Author [Ref.] Crystalluria (%) Aggregates (%) Main crystals Uric acid (%)

N SF N SF N SF N SF

Hallson-Rose[18] 22 48 2 7 Ph and Ox Ox NE NE
Werness el al. [10]* 26 34 NE NE Ca-Ph Ca-Ph 6 9
Daudon et al. [7] 9.4 46 NE NE Ca-Ox Ca-Ox 2.8 3.1
Habdel-Halim [8] 2 9 0 1.4 Ca-Ox Ca-Ox 0 3.6

'Figures refer only to the patients defined in the study as 'idiopathic calcium urolithiasis'.
NE, not evaluated; Ph, phosphate; Ox, oxalate; Ca-Ph, calcium phosphate; Ca-Ox, calcium oxalate.

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Fig. 3. Clockwise from top left: Amorphous phosphates (phase-
contrast, 400 x). Triple phosphate crystals (interference-contrast,
400 x). A star-like calcium phophate crystal (phase-contrast, 400 x).
Calcium phosphate plate (phase-contrast, 400 x). (From ref. 5, with
permission).

(Table 1). They are not found in normal subjects, and

characteristically occur in patients with lipiduria sec-
ondary to nephrotic syndrome, although in our experi-
ence they are less frequent than other lipid particles.
Other crystals which can rarely be found in the urine
include cystine crystals (Figure 4), which precipitate
as symmetrical hexagons, mostly aggregated, and are
constantly birefringent. They are typical of patients Fig. 4. From top to bottom: A large cholesterol crystal (phase-
with cystinuria, but to find them the urine pH must be contrast, 200 x). Hexagonal crystals of cystine (phase-contrast,
lowered to 4.0 with glacial acetic acid and stored 400 x). Leucine crystal (phase-contrast, 400 x). (From ref. 5, with
overnight at 4°C [15,16]. Disappearance of cystine permission).
crystalluria has been observed after the administration
Crystalluria: a neglected aspect of urinary sediment analysis 383

of the benzodiazepine chlordiazepoxide and in associ-
ation with the appearance of nephrotic syndrome in a
patient [16]. The underlying mechanisms are unclear.
Leucine crystals (Figure 4) are oily-looking spheres
with concentric striations, which form pseudo-Maltese
crosses under polarized light. Leucine, like tyrosine,
which appears as thin needles often aggregated in
bundles or rosettes, is typical of patients with hepatic
failure. Other rare crystals, without clinical implica-
tions are those of hippuric acid, which appear as
elongated hexagons, and calcium carbonate, which
usually appear as clumped granules.
Crystalluria in stone formers
Finally, crystalluria has also been studied in patients
with primary hyperoxaluria. Werness et al. [10],
investigating 182 urine voidings from 12 patients,
found crystals in 92% of samples, mostly in moderate
to large amounts, and exclusively due to calcium
oxalate (monohydrate mainly). Interestingly, specific
treatment significantly reduced the incidence of crys-
talluria, a result achieved also by others with ortho-
phosphate and pyridoxine [19].
From all this it appears that crystalluria may be
useful in the study of stone formers, but it must be
emphasized that (1) such a study requires experienced
people and specialized procedures, which are, more-
over, not yet standardized [20]; (2) it is difficult to
identify a stone former on the basis of crystalluria

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alone [10], as even healthy subjects may have crystals
The notion that supersaturation of urine with crystals in the urine.
is the conditio sine qua non for the formation of stones
has led several investigators to study the value of
crystalluria in the identification and follow-up of Crystalluria and acute renal failure
patients with urinary stone disease. Robertson et al.
[17] compared the urine of healthy controls and of The precipitation of massive amounts of crystals within
patients with urinary calculi and found that the preval- the renal tubules can cause acute renal failure due to
ence of calcium oxalate or calcium phosphate crystallu- intratubular obstruction. This process has been demon-
ria was similar in the two groups. The stone formers, strated in acute uric acid nephropathy, in acute renal
however, had larger calcium oxalate crystals (10-12 um failure caused by ethylene glycol poisoning, in a patient
in diameter vs 3-4 um), and only their urine contained with hypereosinophilic syndrome, and in a number of
crystal aggregates, whose diameter ranged between 20 cases after ingestion of drugs (which are described
and 300 um, which increased to 500 um after an oral separately). In all these conditions the finding of crys-
dose of oxalate. talluria has remarkable diagnostic value.
Several other investigators subsequently compared Acute uric acid nephropathy is a condition seen in
normal subjects with stone formers, and all of them patients with aggressive lymphoproliferative disorders
confirmed that crystals could actually be found in or, less commonly with solid tumours. It is a con-
the urine of healthy subjects [7,8,10,18] (Table 2). sequence of a massive tumour lysis which may occur
However, crystalluria was less frequent in normals either spontaneously or more frequently after chemo-
than in untreated stone formers, and also some mild therapy. Tumour lysis results in severe hyperuricaemia
differences were found as far as the predominant secondary to cell breakdown with purine release, and
crystals were concerned. The prevalence and the main the precipitation of uric acid crystals within the lumina
types of crystals in both normal and stone formers of the distal tubules, collecting ducts (where acid-
varied considerably in the different studies, however, ification and concentration are maximal), and peri tub-
which may be attributed to different methods employed ular capillaries [21]. Therefore sustained hydration,
to study crystals. In fact, while Hallson and Rose [18] urine alkalinization, and the administration of large
studied fresh urines (handled at 37°C) by bright-field doses of the xanthine oxidase inhibitor allopurinol to
microscopy and a Coulter counter to quantitate crys- avoid hyperuricaemia are the recommended preventive
tals, Werness et al. [10] used a petrographic microscope and therapeutic manoeuvres.
after recovering crystals by Nucleopore filters. Daudon Massive amounts of uric acid crystals [22-24], or
et al. [7] carried out their study on fresh urine at room 'amorphous material' [25,26] may be found in the
temperature by polarized microscopy in association urine. The latter is usually caused by amorphous
with X-ray spectroscopy, while Abdel-Hamin [8] urates, but in some patients it may be due to crystal-
investigated fresh samples 'almost at body temperature' lized xanthine [27,28], whose blood and urinary con-
by conventional urine microscopy. centrations are increased by allopurinol. Xanthine has
Crystalluria has also been evaluated as parameter to a much lower solubility than uric acid (three times less
monitor the effects of drugs given to prevent stone at pH 5.0, 15 times less at pH 7.0) and hypoxanthine
formation. Hallson and Rose [18] halved the incidence (two times and 11 times less, at a pH of 5.0 and 7.0
of high crystals volume concentration with thiazide or respectively) and therefore its crystallization can
cellulose phosphate, Werness et al. [10] achieved a occur easily.
significant reduction of crystalluria in calcium stone Although massive crystalluria may be seen in
formers treated with orthophosphate or thiazide, while patients with acute uric acid nephropathy, one must
Daudon et al. [7] found that hydrochlorothiazide be aware that it is not invariably present [26], and
at the dosage of 25-50 mg per day did not affect that it may also occur in patients with tumour lysis
crystalluria. but without acute renal failure [28].
184
Acute renal failure from ethylene glycol occurs after
the ingestion (accidental, for suicidal purposes, or as a
substitute of alcohol) of large amounts of this com-
pound, which is contained in antifreeze agents.
Ethylene glycol is transformed by the liver into glycolic,
glyoxalic, and oxalate acids, which are toxic metabol-
ites causing a multisystem disease characterized by
cerebral (mainly coma and seizures), pulmonary (res-
piratory distress), cardiac (mainly arrhythmias), and
renal symptoms [29]. Calcium oxalate crystals are
found in the affected organs, and in the kidneys they
are present in the tubules, both in the cells and in the
lumen. The typical laboratory findings are that of
severe metabolic acidosis, high anion gap, osmolar
gap, and crystalluria.
Crystalluria in ethylene glycol poisoning is massive
and due to monohydrate calcium oxalate crystals with
unusual shape (e.g. short prisms, needles, spindles, or
elongated hexagons similar to hippuric acid) and
strong birefringence [30-33] (Figure 5). However,
common bipyramidal dihydrate crystals can also be
found, especially in the early phases [34]. Crystalluria
taining mainly spindle-like crystals and elongated hexagons, as seen
in ethylene glycol poisoning. (Top, phase-contrast, 400 x; bottom,
polarized light, 400 x).
G. B. Fogazzi
disappears with the removal of ethylene glycol from
blood by dialysis [35]. Early treatment may prevent
crystalluria [36], and occasionally this may be absent
in the advanced phases of the poisoning [37].
Crystalluria in acute renal failure caused by hypereo-
sinophilic syndrome has been reported in only one
patient so far [38]. Charcot-Leyden crystals, one of
the hallmarks of hypereosinophilic syndrome, were
found in the renal tubular lumina and in large amounts
in the urine. Charcot-Leyden crystals are elongated
bipyramids composed of a single acidic protein with a
low molecular weight, and are highly insoluble at
neutral pH.
Table 3 summarizes the main information about
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crystalluria in acute renal failure.
Crystalluria caused by drugs
A variety of drugs may occasionally cause transient
crystalluria, in isolation or in conjunction with other
urinary abnormalities. Overdose, dehydration, or
hypoalbuminaemia, which increases the unbound drug
•vhich is ultrafiltrated by the glomerulus, are the factors
sually favouring the precipitation of crystals within
le tubular lumina [39,40]. Herein crystalluria due to
rugs with the most relevant clinical implications is
ascribed (Table 4).
Sulphadiazine, which is the treatment of choice for
>xoplasma encephalitis in patients with AIDS, is the
ading cause of drug-related crystalluria. Sulphadia-
ne is a short acting sulphonamide, rapidly excreted
y the kidneys and with a low solubility in the urine,
specially at acidic pH. This feature, coupled with high
rug dosages, dehydration, and hypoalbuminaemia,
responsible for the precipitation of sulphadiazine
•ystals and/or calculi within the urinary system, result-
ig in a wide spectrum of renal manifestations, which
iclude asymptomatic crystalluria, haematuria, and
;ute renal failure due to obstructive uropathy or
itratubular obstruction [41-44]. Crystals and stones
issolve with hydration and alkalinization, and the
:nal manifestations usually reverse in a few days.
Sulphadiazine crystals appear as strongly birefrin-
;nt 'shocks of wheat' or 'shells' with an amber colour
ible 3. Crystalluria in acute renal failure
jndition Crystals Remarks
cute uric acid Uric acid Crystalluria not always
nephropathy Amorphous urates present
Xanthine Crystalluria possible
without acute renal
failure
:hylene glycol Atypical Crystalluria prevented by
poisoning calcium oxalate early treatment
monohydrate Crystalluria occasionally
absent
Hypereosinophilic Charcot-Leyden —
syndrome
Crystalluria: a neglected aspect of urinary sediment analysis 385
Table 4. The main types of crystals due to drugs receiving acyclovir is not yet defined. For the time
being, however, it is wise to consider the appearance
Drug Crystal Clinical of acyclovir crystalluria as a potential insult to the
manifestations kidney, which should prompt the hydration of the
patient and the reduction or the withdrawal of the drug.
Sulphadiazine Birefringent 'stooks of Isolated crystalluria, Acyclovir crystals are birefringent and needle-shaped
wheat' or 'shells' with haematuria, ARF, [Figure 7], and when in abundance give to urine a
striation stones
Acyclovir Birefringent fine needles Isolated crystalluria, silky and opalescent macroscopic appearance [46].
ARF The diuretic triamterene, can cause a transient and
Triamterene Birefringent coloured ARF, ?stones asymptomatic crystalluria in acidic urine [50,51].
spheres (brown, green, However, a case of irreversible acute renal failure with
orange, red) intratubular precipitation of triamterene crystals (but
Piridoxylate Asymmetrical hexagons Stones
or rectangles with without crystalluria) has been reported [52]. Therefore
rounded extremities triamterene crystals too should be regarded as a poten-
Primidone Birefringent hexagons Isolated crystalluria, tial cause of severe tubular injury. The role of triamter-

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transient ene crystals in favouring the formation of urinary stone
proteinuria
and haematuria
is still matter of debate [53]. Triamterene crystals are
spherical and predominantly brown in colour, and
ARF, acute renal failure.
under polarized light they appear as 'Maltese crosses'.
In most cases these crystals are associated with brown
casts, which are also due to triamterene.
and a radial striation, for which they are easily distin- Piridoxylate, an equimolar combination of glyoxylic
guishable from other sulphonamide crystals [45] acid and pyridoxine, used in some European countries
(Figure 6). The search for these crystals in the urine is for the treatment of coronary disease, can cause a
one of the measures suggested to monitor the patients unique calcium oxalate trihydrate crystalluria, which
under sulphadiazine therapy [43]. Although their pres- is usually associated with piridoxilate stones [54].
ence alone may not indicate a renal injury, their finding Crystals are asymmetrical hexagons, which disappear
should encourage hydration and alkalinization, if not completely from the urine after withdrawal of the drug.
a reduction or discontinuation of the drug. The barbiturate primidone can be a cause of crys-
The antiviral agent acyclovir can cause crystalluria
especially when given intravenously at high dosages
and to dehydrated patients. Crystalluria may either be
asymptomatic [46] or associated with acute renal fail-
ure, which is usually reversible after discontinuation
of the drug [47]. However, intratubular crystals after
acyclovir were found only in animals [48], and a case
of acute tubular necrosis without intratubular crystals
and crystalluria during acyclovir therapy has been
described [49]. Therefore the real role of crystalluria
in the pathogenesis of acute renal failure in patients

V ~-
Fig. 7. Acyclovir crystalluria (bright-field microscope, 1800 x).
Fig. 6. A typical 'stook of wheat' crystal of sulphadiazine as it (From Potter JL and Krill CE. Acyclovir crystalluria. Pediatr Infect
appears under polarized light (256 x ) . Dis J 1986; 5: 710-712 with permission).
386
talluria following overdose [55,56]. The urinary abnor-
malities include isolated crystalluria or crystalluria
associated with transient haematuria and proteinuria
[55]. Crystals are birefringent hexagons which come
singly or in conglomerates. In the latter case they can
resemble crystals of cystine [56].
Other drugs such as quinolones, cephalexin, sulpha-
methoxazole, aspirin, xylitol, etc. can occasionally
cause crystalluria, without relevant clinical implica-
tions, however.
Conclusions
Crystalluria is a frequent finding, about 8% of samples
in author's experience. Most of the times it is the
consequence of a transient supersaturation of urine
caused by the ingestion of some foods or by changes
of urine temperature and/or pH, which occur upon
standing after micturition. In a minority of cases,
however, crystalluria is due to pathological events,
some of which can affect the kidneys seriously. In these
cases, crystalluria is diagnostically useful and is also
important to follow the course of the disease. Even in
these circumstances, however, a proper methodological
approach is necessary and crystalluria must be matched
with other laboratory tests and with the clinical
findings.
Acknowledgement. The author is grateful to Dr See-Odd Leong,
Department of Medicine, National University Hospital, Singapore,
for valuable help in reviewing the manuscript.
Note added in proof
Since completion of the manuscript it has been shown
that the vasodilator naftidrofuryl oxalate also can
cause crystalluria associated with acute renal failure
(see Le Meur, Moesch, Rince et al. Nephrol Dial
Transplant 1995; 10: 1751-1755).
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