DIFFERENT CAST IN URINE AND THEIR SIGNIFICANCE

Dr. Nitin G Rathod

Date : 2ndNov 2016
 CONTENTS OF SEMINAR

INTRODUCTION
URINARY SEDIMENTS
METHODS OF EXAMINING URINE SEDIMENTS
MICROSCOPES USED FOR STUDYING URINARY SEDIMENTS
FORMATION OF CASTS AND THEIR TYPES
CLINICAL SIGNIFICANCE
CONCLUSION
 INTRODUCTION

 Important in the present era of clinical practice where treatment has

become solely dependent on laboratory values.

Microscopic examination of the urine sediment is an essential part of

the urinalysis, as it
enables confirmation and clarification of urine dipstick findings and al
so the identification of structures that are not
evaluated by the urine dipstick (eg, epithelial cells, casts, crystals).
 URINARY SEDIMENTS

Urine consists of various microscopic, insoluble solid elements in

suspension.

These elements are classified as organized or unorganized.

Organized substances include red blood cells, white blood cells,

epithelial cells, casts, bacteria and parsites.

The unorganized substances are crystalline and amorphous material.

 METHODS OF EXAMINING URINE SEDIMENTS

Generally random urine sample is satisfactory .

However early morning mid stream urine is best for evaluation.

 Examination takes place when the sample is fresh.

Cells and casts begin to lyse within 2 hours of collection.

Refrigeration (2-8 degree C) helps prevent lysis of pathologic entities

however this may increase precipitation of various amorphous and
crystalline elements.
 REAGENTS USED

A crystal violet safranin stain is commonly used for delineation of

formed elements.

Supravital stain reagents – a combination of 3 parts of solution 1 (

crystal violet 3gms, ethyl alcohol 95 % 20ml, and ammonium oxalate
0.8 gms) and 97 parts of solution 2 ( safranin O 1 gm, ethyl alcohol 95
% 40 ml and distilled water 400 ml ) are mixed and filtered.

. Others -2 % solution of methylene blue and toluidine blue.

MICROSCOPES USED FOR STUDYING URINARY SEDIMENTS

1) Bright field microscopy - routinely used for unstained

urine preparations.
Disadvantages – identification of leucocytes,histiocytes,
renal tubular epithelial cells and casts are difficult.
2) Phase contrast microscopy – useful in detecting
translucent formed elements such as casts.
3) Polarised microscopy – used to distinguish crystals and
fibres from cellular and protein cast material.
 URINE CASTS

Urine casts are cylindrical, cigar-shaped structures produced by the kidney

and present in the urine in certain disease conditions.

They have a definite outline, showing parallel sides and 2 rounded ends.

A significant number of urinary casts usually indicates the presence of

renal disease, rather than lower urinary tract disease.

Different forms such as broad casts ( seen in dilated tubules ) or thin cast (
due to compression of swollen interstitial tissue) or they may be short and
stubby or long and convoluted.
 CONTINUE

All casts have a matrix of Tamm- Horsfall mucoprotein to which other

proteins or elements may be added.

They are approximately 7 or 8 times the diameter of an RBC and

several times longer than wide.

Casts are classified primarily on the basis of morphologic features;

various types have different clinical implications.
 FORMATION OF CASTS

Urinary casts are formed only in the distal

convoluted tubule (DCT) or the collecting
duct.

The proximal convoluted tubule (PCT) and

loop of Henle are not locations for cast
formation.

Casts are the result of solidification of

material (protein) in the lumen of the
kidney tubules.
 CONTINUE

Once formed, these casts of the tubule are eliminated via the urine
and may be seen in the urine sediment.

They may contain RBCs, WBCs, renal epithelial cells, fat globules,
bacteria, anddegenerated forms of any of these structures, which are
seen as granules.

Aggregates of plasma proteins, including fibrinogen, immune

complexes, and globulins, may also be seen as granules within a cast.
 Types of urinary Casts

Acellular Casts Cellular Casts

Hyaline Casts Red Blood Cell Casts

Granular Casts White Blood Cell Casts

Waxy Casts Bacterial Casts

Fatty Casts Epithelial Cell Casts

 HYALINE CASTS

Hyaline casts are the most common type of casts which are
composed of solidified Tamm-Horsfall mucoprotein.

They have smooth texture and a refractive index very close to that of
the surrounding fluid.

Generally, hyaline casts have parallel sides with clear margins and
blunted ends.
 CONTINUE

Hyaline casts can be seen even

in healthy patients.
Normally seen – 2-3 casts/ hpf.
They may be seen in increased
numbers during dehydration,
exercise
or diuretic medicines,fever.
 GRANULAR CASTS

Granular casts result either from the degeneration of cellular casts,

or direct aggregation of plasma proteins or immunoglobulin light
chains.

They have a textured appearance which ranges from fine to coarse in

character.

Their appearance is generally more cigar-shaped and of a higher

refractive index than hyaline casts.
 CONTINUE

They are seen after stenous

exercise, chronic renal diseases,
acute tubular necrosis etc.
 WAXY CASTS

Waxy casts represent the final stage of degeneration of cellular casts.

They are more refractile and therefore easier to see compared to

hyaline casts.

They are uaually seen in tubular injury of a more chronic nature than
granular or cellular casts like severe chronic renal disease and renal
amyloidosis.

These casts are also called renal failure casts.

 CONTINUE

• WAXY CASTS
 FATTY CASTS

Fatty casts are formed by the breakdown of lipid-rich epithelial cells.

These contain lipid droplets within the protein matrix of the cast and
are identified by the presence of refractile lipid droplets.

They are usually seen in the conditions like tubular degeneration,

nephrotic syndrome, hypothyroidism etc.
 CONTINUE

• FATTY CASTS
 CELLULAR CASTS

A cellular cast may be composed of any of the cells found in the urine
sediment, such as RBC, WBC, or renal tubular epithelial cell.

The cellular cast appears to result from a clumping of cells that are
incorporated in a protein matrix.
 RBC CASTS

Red blood cells may stick together and form red blood cell casts.

RBC Casts RBCs may be found in a cast either as the result of leakage
of RBCs through the glomerular membrane or by bleeding into the
tubules at any point along the nephron.

Such casts are indicative of glomerulonephritis, with leakage of RBC’s

from glomeruli, or severe tubular damage.
 CONTINUE

Acute post streptococcal

glomerulo nephtitis and other
acute glomerulo nephritides, IgA
nephropathy, and lupus nephritis.

They may also be seen in cases of

subacute bacterial endocarditis,
renal infarction, and rarely in
severe pyelonephritis.
 CONTINUE

Other forms of RBC casts include blood casts and hemoglobin casts,
which are the result of degeneration of RBCs within the cast matrix.

The cells are no longer visible, yet the remaining hemoglobin

pigment imparts a characteristic orange-yellow or red-brown color,
which distinguishes them from waxy casts.

This breakdown of cells within the cast suggests urinary stasis and a
condition more chronic than acute.
 WBC CASTS

White blood cells (generally neutrophils) are present within or upon

casts.

These casts are typical for acute pyelonephritis, but they may also be
present with glomerulonephritis.

They may also be seen in acute interstitial nephritis, lupus nephritis,

and acute papillary necrosis.
• WBC CASTS

• White cell cast in which blue stai

ned white cells are contained wit
hin a granular cast.
 Renal Tubular Epithelial Cell Casts

These casts are composed of renal epithelial cells.

They may be difficult to distinguish from WBC casts, especially as

they begin to degenerate into granular casts.

The most reliable criteria being its single round nuclei.

 CONTINUE

These casts are seen in

conditions such as renal tubular
necrosis, viral disease (such as
CMV nephritis), and kidney
transplant rejection.
And exposure to nephrotoxic
substances such as mercury,
ethylene glycol, and various
drugs.
 BACTERIAL CELL CASTS

Bacterial casts are casts composed of bacteria in a protein(hyaline)

matrix.

The bacteria might be closely packed, diffusely scattered, or

concentrated in an area of the cast; WBCs are also frequently present.

Bacterial casts may be misidentified as granular or cellular casts.

 CONTINUE

They may be identified by Gram staining the dried (cytocentrifuged)

sediment.

Bacterial casts are diagnostic of acute pyelonephritis or intrinsic renal

infection.
OTHER CASTS
 CRYSTAL CASTS

Casts containing urates, calcium oxalate, sulfonamides are

occasionally seen.

Crystal casts are associated with more often hematuria.

These casts should be separated from the clumps of crystals formed

at room temperature.

The clinical significance is that of the crystal in question.

 PIGMENTED CASTS

Hemoglobin casts – seen in glomerular and tubular diseases, less

commonly in hemoglobinuria.

Hemosiderin casts – derived from pigment laden renal tubular cells.

Myoglobin casts – red brown in color and found in acute muscle

damage. May also be seen in acute renal failure.

Bilirubin and other drug casts – bilirubin seen in urine following

obstructive jaundice, imparts deep yellow brown color to casts.
PIGMENTED CASTS
SUMMARY OF URINE CASTS AND SIGNIFCANCE
Casts Composition Associated Conditions

•Normal individuals
Hyaline casts Solidified Tamm-Horsfall mucoprotein •Dehydration
•Heavy exercise

Various cell types (Degeneration of cellular •After sternous exercise

Granular casts casts, Aggregates of plasma proteins or •Chronic renal diseases
immunoglobulin light chains) •Acute tubular necrosis

Various cell types (Final stage of •Severe chronic renal disease

Waxy casts (renal failure casts)
degeneration of cellular cast) •renal amyloidosis

•Tubular degeneration
Lipid droplets within the protein matrix of
Fatty casts •Nephrotic syndrome
the cast
•Hypothyroidism

•Pyelonephritis
•Glomerulonephritis
RBC Casts Red Blood Cells
•Acute interstitial nephritis
•Lupus nephritis

WBC Casts White Blood Cells •Glomerulonephritis

•Renal tubular necrosis

Epithelial Cell Casts Renal Tubular Epithelial Cells •Viral Diseases
•Kidney transplant rejection

•Acute pyelonephritis
Bacterial Cell Casts Bacterial Cells
 CONCLUSION

Conclusion Casts in the urine sediment have various origins or

mechanisms of formation and clinical relevance.
The presence of casts of all types indicates renal involvement.
Casts represent different disease states; eg, RBC casts are most
associated with glomerular disease.
Whereas WBC casts are indicative of tubular disease, especially
infection and acute pyelonephritis.
Casts must be properly identified so that meaningful diagnosis can be
made.
 REFERENCES

ROBIN’S BASIC PATHOLOGY 6th EDT.

HENRY JB – CLINICAL DIAGNOSIS AND MANAGEMENT BY LABORATORY

METHODS.

interpretation [cytology] Casts in the Urine Sediment Karen M. Ringsrud,

MT(ASCP) From the Department of Laboratory Medicine and Pathology,
University of Minnesota Medical School, Minneapolis, MN

WHO. MANUAL OF BASIC TECHNIQUES FOR A HEALTH LABORATORY.

THANK YOU
 Crystals

Those present in acidic urine –

Uric acid crystals –
- usually of various shapes ( diamond , rosette, plates) and
yellow or red brown in color , they are soluble in alkali,
and insoluble in acids.
- Seen in gout , leukemia.
- They may be confused with cysteine crystals that also form in acid urine
because of their flat hexagonal shape.
 Calcium oxalate crystals
- they are colorless, refractile, envelope
shaped.
- Sometimes dumb bell or peanut forms may be seen.
- Increased in urine after ingestion of tomatoes, cabbage,
spinach,asparagus and rhubarb.
- Presence of increased number may also suggest oxalate
stones ethylene glycol poisoning.
Amorphous urates –
- urates salts of potassium,
magnesium or calcium in acid
urine.
- they are usually yellow fine
granules in compact masses.
They are soluble in alkali or
saline at 60 degree C.
Crystals present in alkaline urine –
Calcium carbonate crystals –
- uncommon crystals, small and
colorless and are dumb bell
or spherical shaped.
- They are soluble in acetic acid
and produces CO2.
Phosphate crystals –
Triple phosphate (ammonium magnesium phosphate )-
- they are colorless, shiny 3- 6 sided prisms with oblique
surface at the ends,(coffin lids) or may have feathery fern
appearance.
3) Amorphous phosphate –
- They are colorless granules andare dispersed.
- All phosphates are soluble in acetic acid.
4) Ammonium urate crystals –they appear as cactus
like and are called thorn apple crystals. They are soluble in
acetic acid and are yellow brown in appearance.
 Calcium hydrogen phosphate –
- they are basically colorless, of various shapes
(star shaped, plates, needles) .
Amorphous phosphate –
- They are colorless granules andare dispersed.
- All phosphates are soluble in acetic acid.
Ammonium urate crystals –they appear as cactus
like and are called thorn apple crystals. They are soluble in
acetic acid and are yellow brown in appearance.
 Abnormal crystals

1) Cysteine crystals –
- Generally colorless, having
hexagonal structure,
- Occur in layers, high refractibility
and soluble in 30% HCL
are its features.
- Seen in acidic urine and are due
to inborn errors of
cysteine metabolism. Often
cysteinuria is associated with
cysteine stones.
2) Leucine crystals –
- these are refractile, yellow or
brown spheres with
radial and concentric
striations. Found in liver cirrhosis.
Tyrosine crystals –
- found in inborn error of
tyrosine metabolism,
and liver cirrhosis, they appear
as clusters of fine, delicate,
colorless or yellow needles.
Sulfonamide crystals –
- They appear as sheaves of
needles.
- They are found following
sulfonamide therapy. These
crystals dissolve in acetone.
 Bilirubin crystals –
- the crystals of bilirubin are of
various shapes
(square, bead like or fine
needles).
- They are seen in obstructive
jaundice.
Cholesterol crystals –
- They are colorless, refractile, flat,
rectangular
plates with notched corners and
appear as stair step
pattern.
- They are soluble in ether,
chloroform or alcohol.
- Seen in nephrotic syndrome,
hyper cholesterolemia.
- They can be detected under
polarizing microscope.
OTHER URINARY SEDIMENTS
1) Bacteria –
- detected in urine by
microscopy also, presence of 1
bacteria per hpf corresponds
to significant bacteriuria.
- The most commonly found
bacteria are gram negative
bacilli especially e.coli and
klebseilla species.
2) Yeast cells –
- They appear similar to the
RBCs but are generally oval,
are refractile and demonstrate
budding.
- Presence of candida suggest
immune compromised state,
vaginal candidiasis,DM.
Trichomonas vaginalis –
- motile organisms with pear
shape with
undulating membrane on one
side and 4 flagellae, they are
found as contamination in
female urine during vaginitis.
4) Microfilariae –
- They are seen due to rupture
of urogenital lymphatic
vessel and result in chyluria.
Sperms –
seen in retrograde ejaculation in
males, and following intercourse
in females, they appear as a cap
with a long tail.