CLINICAL PATHOLOGY LABORATORY 6 – Urinalysis and Fecalysis USTMED ’07 Sec C – AsM [email protected]
URINARY SEDIMENTS 1. Cells
- cells present in urinary sediment include WBCs, RBCs and epithelial cells. These cells can be anywhere in the urinary tract from the tubules to the urethra.
Type Description Normal
Values Clinical implications
Red blood
cells Uniform colorless smooth biconcave disks 7um
0-3/hpf Can originate from any part of the urinary tract Glomerulonephritis Trauma
Systemic and renal diseases White
blood cells Spherical with dull gray color. Tend to be
neutrophils. 10-12 um
0-5/hpf (M)
0-8/hpf (F) Acute infection of kidney (pyelonephritis) Cystitis (bladder) Urethritis (urethra) Urinary tract infections Squamous
epithelial Large, flat, irreg shaped cells that contain small central nucleus Abundant cytoplasm Cell size:23-40um
Few Occur in urethra and
vagina Vaginal
contamination
Renal
epithelia Slightly larger than WBC with round central nucleus Cell size: 20 um Occasional Originate in convoluted and collecting tubules Increased numbers indicate tubular injury and damage to epithelial BM Transitional
epithelial Can be round or pear shaped with tail like projections
Rare Line urinary tract
from urinary pelvis to upper portion of urethra Increased amounts indicate disease of bladder or renal pelvis Oval fat
bodies Renal epithelial cells with lipid that are highly refractive, coarse droplets in various sizes
Negative Result from tubular epithelial degeneration of nephron
Are associated with large amounts of protein
Nephrotic syndrome 2. Casts
- Casts are cylindric structures formed primarily within the lumen of the distal convoluted tubule and collecting duct. The major constituent of casts is Tamm-Horsfall protein, a glycoprotein excreted by the renal tubular cells.
Type Description N. Values Clinical Implications
Hyaline Colorless, homogenous, semi-transparent
0-2/lpf Can indicate mild to severe renal disease when increased in numbers
Can be found in healthy individuals after heavy exercise
Red blood
cell cast RBCs in hyaline matrix. Extremely fragile,
degenerate to granular casts
Negative Intrinsic renal disease Acute glomerulonephritis Acute interstitial
nephritis Severe nephritis
White blood
cell cast WBCs in hyaline matrix Usually neutrophils
Negative Renal Inflammation Renal infection Pyelonephritis Chronic renal disease Acute glomerulonephritis Renal tubular epithelial cell Renal Tubular epithelial cells in hyaline matrix
Negative Interstitial tubular disease Vascular disease Toxins
Granular
Cast May be coarsely or finely granular Disintegration of cellular casts or from tubule lysosomes or protein aggregates
Nonpathologic (seen with Hyalin casts) – after strenuous exercise in stress
Pathologic – Glomerulonephritis Pyelonephritis
Waxy Homogenous with
well defined edges that are sharp and have blunt irregular ends
Cracks on lateral edges
Negative Tubular obstruction with prolonged stasis Called renal failure casts Severe chronic renal
failure
Malignant hypertension Acute renal disease Diabetes mellitus Cylindroid Resemble casts but
have one end that tapers to a tail
0-2/hpf Found in conjunction with casts and have same significance
Fatty casts Associated with oval fat bodies and urinary lipids Highly refractile,
contain yellow-brown fat droplets
Negative Seen in disorders causing lipiduria (nephritic syndrome)
Mucous
threads Long thin waxy threads, very transparent
Occasiona
l Can be found in small number in normal urine
Increased numbers indicate inflammation or irritation of the urinary tract 3. Microorganisms and Parasites
Type Description Normal
Values Significance
Bacteria Color: colorless Shape: Rods or cocci
may be found single or in chains Free of bacteria in kidney and bladder
Can be contamination from external sources Rapidly multiply in improper stored specimen With increased WBCs, indicative of urinary tract infection Yeast Color: colorless cells
Shape: ovoid smooth cells with doubly refractile walls Often show budding
and pseudohyphae Sometimes mistaken
for RBCs
Negative Found in urinary tract infections, especially from diabetic parents Immunosuppressed patient Skin or vaginal infection
Spermatozoa Oval heads with long
thin tails Can be found in both male and female urine
Male: nocturnal emission, ejaculation and disease of the genital organs Female: after coitus
Trichomonas
vaginalis Turnip shaped flagellates with three anterior flagella and one anterior flagellum Confused with WBCs Needs to be mobile for identification
Negative Transmitted sexually, frequently infection of vagina and vulva in females
In males, the organisms infects urethra Enterobius
Vermicularis Ova have one flat and one round side with transparent shell. Developing larvae can be seen
Negative Usually found in children and in fecal
contamination
Female worm lays her eggs in perirectal region, and during collection they can be carried into urine specimen
Schistosoma
Hematobium Ovium measures 50-150 um Clear and colorless
with characteristic terminal spine
Negative Inhibits veins in urinary bladder
Endemic in Africa, Nile Valley and Middle East
4. Crystals
- Crystals are frequently found in the urine. They are formed by the precipitation of urine salts subjected o changes in pH, temperature or concentration, which affect their solubility. Crystals are identified by their appearance, solubility and pH.
Type Description pH Solubility Significance
Uric acid Color: yellow-brown Shape: different shapes, most common are diamond, rhombic plates in clusters, lemon shape Acid Alkali-soluble, sodium hydroxide
Associated with renal stones, gout, high purine metabolism, acute febrile conditions, chronic nephritis
Calcium
oxalate ColorlessEnvelope with intersecting diagonal lines Birefringent Acid/ Neutral HCl-soluble Acetic acid insoluble Can be found in normal individuals after ingestion of oxalate rich food and large doses of vitamin C
Associated with renal stones, diabetes mellitus, liver disease and chronic renal disease Hippuric
acid Color: yellow-brown to colorless Shape: elongated
prisms/plates with pyramidal ends
Acid/
Neutral Soluble in water, alkali Insoluble in acetic acid
Associated with diets high in fruits and vegetables containing large quantities of benzoic acid Sodium
urate Color: yellow to colorless Shape: needle or
slender prisms in sheaves or clusters
Acid Soluble at
60oC Report as urate crystals
No clinical significance
Amorphous
urates Color: brick-dust, yellow brown Shape: small granular pink precipitation at refrigeration Salts of Na,Ca,K,Mg Acid/
Neutral Soluble at 60oC and
alkali Acetic acid- insoluble No clinical significance Triple Phosphate (ammonium-magnesium phosphate) Colorless
Shape: three to six sided prisms described as coffin-lid shaped Alkaline Neutral Soluble in dilute acetic acid
Associated with renal calculi, chronic pyelitis, enlarged prostate, urinary tract infection Found in normal urine
Amorphous
phosphates ColorlessShape: granular patches with no definite shape Alkaline Soluble in acetic acid Insoluble at 60oC No clinical significance Calcium
carbonate ColorlessShape: small dumbbells or spherical forms; can be found in granular masses or in pairs Alkaline Soluble in acetic acid No clinical significance Calcium
Phosphate ColorlessShape: long, thin prisms with one pointed and arranged as rosettes or clusters of needles
Thin irregular plates that float on surface of urine
Alkaline Soluble in acetic acid
Associated with renal calculi
Can be found in normal urine
Ammonium
Biurate Color: yellow to brown Shape: Spherical
bodies with long irregular spicules
Alkaline/
Neutral Soluble in acetic acid and warming
Usually indicates old urine
Abnormal Crystals
Cystine Colorless and refractile Shape: hexagonal
with equal and unequal sides Appear single or in clusters Acid Soluble in HCl, alkali, and ammonia
Amino acid crystal, inherited as a metabolic defect that prevents reabsorption of cystine Leucine Color: yellow to
brown Shape: spheroids with radial concentric striations Highly refractile with oil-like appearance Acid Soluble in hot acetic acid, hot alcohol and alkali
Maple syrup disease Severe liver disease
Tyrosine Color: black or yellow with presence of bilirubin Shape: highly refractile needles occurring in sheaves or clusters Acid Soluble in HCl, NH4OH, dilute mineral oil
Severe liver disease and tyrosinosis
Cholesterol Color: transparent Shape: regular to irregular flat plates with one corner notched out, may be single or in larger #s Most often found
after refrigeration Acid/
Neutral Soluble in chlorofor m, ether, hot alcohol Insoluble in alcohol Excessive tissue breakdown Seen in nephritis and
nephritic syndrome Lipiduria, lipidemia
and lymphatic obstruction due to neoplasms Bilirubin Color: yellow to
brown to reddish Shape: Granules or clusters acid Soluble in chlorofor m, acetone, acid and alkali Obstructive jaundice Bilirubin must be present in urine
Sulfa Color: brown to
yellow Shape: needle-like shapes seen in bundles or sheaves Stacks of wheat acid Soluble in
acetone Most sulfonamide drugs are more soluble than older types
Ampicillin Colorless Shape: elongated
long thin needles
acid Administration of
large parenteral doses
Radiographic
media Color: hypaque (opaque?), appear dark and thick Shape: pleomorphic
needles, single or sheaves
acid Soluble in
10% NaOH Intravenous injection for radiography Can appear up to 3
days after injection Hemosiderin Color: yellow to
brown to red Shape: heavy large
granules Prussian blue stain
for iron
Acid/
alkaline Insoluble granules Associated with anemia and destruction of RBC
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