The document discusses routine urinalysis microscopic examination including proper specimen collection and handling, elements seen in urine sediment, epithelial cells, red blood cells, white blood cells, casts, crystals, and correlation with physical and chemical tests. Quality control and types of elements seen are also covered.
The document discusses routine urinalysis microscopic examination including proper specimen collection and handling, elements seen in urine sediment, epithelial cells, red blood cells, white blood cells, casts, crystals, and correlation with physical and chemical tests. Quality control and types of elements seen are also covered.
The document discusses routine urinalysis microscopic examination including proper specimen collection and handling, elements seen in urine sediment, epithelial cells, red blood cells, white blood cells, casts, crystals, and correlation with physical and chemical tests. Quality control and types of elements seen are also covered.
The document discusses routine urinalysis microscopic examination including proper specimen collection and handling, elements seen in urine sediment, epithelial cells, red blood cells, white blood cells, casts, crystals, and correlation with physical and chemical tests. Quality control and types of elements seen are also covered.
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Routine Urinalysis
Microscopic Examination of Urine
Urinary Sediments Formed elements: epithelia, red cells, white cells Crystals Mucus Renal casts Microorganisms Sternheimer-Malbin stain Proper Specimen
Collection Patient prep may or may not be done
Random, clean catch,
catheterized, etc Rapid transport to lab Room temperature, refrigerated specimen Prompt examination Within 30 minutes of collection ideal Volume of urine evaluated Well-mixed urine 12 milliliters (10-15 mL range) routine volume analyzed Consistent examination Minimum 10-12 representative fields
Elements must be evenly
distribute throughout slide If not, prepare another wet prep Ensure Accuracy in Reporting Microscopic results should be correlated to the physical and chemical results
Microscopic UA Correlate with cloudiness and other findings Quality control Consistent volume
Centrifugation Well mixed fresh specimen Microscopy (wet mount, use low light) Sternheimer-Malbin stain
Supra-vital stain used to
increase visibility of structures. Assists greatly in differentiating renal tubular epithelial cells (which will take on an eosinophilic - oranges
cytoplasm & dark
purple nuclei) from transitional epithelial (which are more overall blue)
Types of Sediment Cells Casts Crystals Critters
Types of Sediment Organized biological part RBC WBC Casts Epithelial cells Bacteria, parasites, yeast and fungi
power (10X). Look for casts, mucous, and squamous epithelial cells in general getting an overall feel Report squamous epithelial cells, crystals, mucous, etc. using semiquantitative terms such as rare, few, moderate, or many (or trace, 1+,2+,3+, & 4+) according to lab protocol. Enumeration - quantitate. Method may vary from lab to lab Average number of RBC/hpf Average number of WBC/hpf
Average number of any renal
tubular or transitional epithelial cells /hpf. .Changes in urine sediment when allowed to stand important to keep in mind the changes in microscopic structures that can occur (dont forget the other chemical changes ie bilirubin, pH, ketones) RBC distorted crenation, swelling, disintegration WBC disintegrates in alkaline urine
Cast disintegrate in alkaline urine
Bacterial growth increased alkalinity Increased precipitation of crystals, especially amorphous
Epithelia Squamous epithelia
Large flat cell with central oval
nucleus
Transitional (bladder) epithelia
Spindle shaped with large oval nucleus Maybe in sheet
Renal tubular epithelia
Small cell with large oval nucleus
Most clinically significant
Epithelial Cells
Normal: small amount
Abnormal: infections, disease
Squamous Epithelial Cells
Most common type of epithelial
cell found in urine Originates in superficial lining of urethra and vagina Increased numbers may indicate poor collection technique
Transitional Epithelial Cells
Originates in lining of renal pelvis,
ureters, BLADDER, upper urethra Increased numbers may indicate urinary tract infection (UTI), collection by catheterization, malignancy
Renal Tubular Epithelial Cells
Originates in lining of RENAL
TUBULES Increased numbers indicate tubular necrosis Squamous Epithelial Cells Largest epithelial cell found in urine Enumerate using low power objective Cells are thin and flat; central nucleus Fine granulation in cytoplasm that becomes dense as cell degenerates
Clue Cells Squamous epithelial cells with large amount of bacteria adhering to them giving them a shaggy appearance Originates in vaginal mucosa, so considered vaginal contaminant;
presence indicates bacterial vaginal
infection
Transitional Epithelial Cells
Size varies dependent upon location in urinary tract Most common type seen in urine originates in the bladder Generally much larger than WBC with abundant cytoplasm; nucleus to cytoplasm ratio ~ 1:5 Nucleus generally centrally located Borders of nucleus and cytoplasm distinct Leukocytes Pus, or pyuria
May indicate urinary tract infection
UTI if more than 10/HPF. Normal: 0-8 WBC/hpf Glitter cells in dilute alkaline urine WBC in urine: leukocyturia Indicates infection ( bacterial, nonbacterial) Neutrophil predominant type of WBC found in urine WBC: leukocytes Spherical Contain nucleus, granules etc Approximately 2x larger than RBC WBC: leukocytes Cytoplasm contains granules
Nucleus is segmented (lobed)
Can be found singly or in clumps
Hypotonic (dilute) Urine
Dilute urine: WBC swell and then lyse Glitter cells: swollen WBCs showing brownian movement Hypertonic (concentrated) Urine WBC become smaller, due to water moving out of the WBC Unlike RBC, WBC do not crenate WBCs can resemble: Renal tubular epithelial cells
Crenated RBC WBC Correlation: Correlate microscopic evaluation with Physical exam Odor (infection) Clarity Chemical exam Positive reagent strip for leukocyte esterase Non-granular WBC (lymphocytes) will not react with reagent strip reaction (false negative) Erythrocytes Hematuria may indicate renal damage
Menstrual contamination May be crenated or ghost cells Intact RBC: hematuria Normal: 0-3 /hpf Abnormal: damage to basement membrane of glomerulus, kidney infection, kidney stones, trauma
RBC can resemble:
Yeast Oil droplets, air bubbles Calcium oxalate crystals, oval form In concentrated urine, RBC will crenate and resemble WBC
RBC Correlation Correlate microscopic evaluation with Physical exam Color Clarity Chemical exam Positive reagent strip Ascorbic acid: causes false negative result Myoglobin: causes false positive result Casts Presence of casts reflect health status of renal tubules
Number and type of cast is
significant Increased amounts of casts: usually also have a positive protein dipstick Enumerated: lpf Identified: hpf Casts Normal: few hyaline or few granular casts Abnormal: increased number and type of cast significant Certain types of casts are always pathologic: RBC, WBC Casts are only formed in the kidney tubules: not the bladder, not urethra, not ureters
Structural Makeup of Casts
Consists of a uromodulin matrix Uromodulin is a glycoprotein formerly called the Tamm-Horsfall protein This protein matrix does not react with the protein reagent strip test Cast Formation Enhanced By: Acidity of urine Increased solute concentration Decreased urine flow rate (urine stasis) Presence of plasma proteins (albumin, globulins, hemoglobin, myoglobin) Characteristics of Casts
Cylindrical, cigar shape, parallel
sides Vary in length and width Mucus and fibers can be misidentified as casts Cast Identification/Classification Enumerate using low power objective; Identify using high power objective Classified by substance incorporated into cast matrix Cast Identification/Classification Youngest cast is the hyaline and cellular, oldest is waxy
Cast becomes granular and then
waxy as the cast ages and substances inside the cast degenerate Renal Casts Cylindruria Renal stasis Acidic pH Proteinuria Concentrated urine
Tamm-Horsfall mucoprotein matrix
Renal Casts Hyaline
Least significant Not refractile
Coarse and fine granular
Cellular
Classified by cells in the cast
Waxy
End stage renal disease
Hyaline Cast Low refractive index and homogeneous matrix makes this cast very hard to see using bright field microscopy Adjust condenser to enhance visualization Phase microscopy used to enhance visualization Lower the condenser to enhance visualization of casts and mucus Hyaline Cast Most common cast seen in normal individuals
Normal: 0-2 hyaline casts/lpf
Increased amounts seen with dehydration, fever, emotional stress, strenuous exercise
Waxy Cast Highly refractile, homogeneous texture, well defined edges, blunt uneven ends May see cracks along the length of the cast May appear yellow to gray to colorless
Significance: pathologic (prolonged stasis) Fatty Cast Highly refractile due to fat content Fat in the form of free fat droplets or oval fat bodies inside the cast Identify using polarized microscopy: look for characteristic maltese cross formation Significance: pathologic finding, often seen in Nephrotic Syndrome Cast Correlation
Correlate microscopic evaluation
with Physical exam Clarity Chemical exam Protein reagent strip Why ? Mucus Usually of no clinical significance Crystals Not normally found in fresh urine If found in fresh urine, pathologic Crystals precipitate as urine cools to room temp or when urine is refrigerated
All clinically significant crystals are
found in acid urine Crystal Formation Enhanced By Increased concentration of solute in urine Urine pH Urine stasis Temperature Crystal Identification Microscopic appearance Urine pH
Crystal Correlation Correlate microscopic evaluation with Physical exam Color Clarity Chemical exam pH Crystals Normal acid pH crystals Normal alkaline pH crystals Pathologic crystals found in acid or neutral urine Drug induced crystals Normal Acid pH Crystals
Amorphous urates Uric acid Calcium oxalate Common Crystals in Acid pH Amorphous urate
Orange powder May clear with warming or saline
Uric acid
Brown lemon shaped or star shaped
Birefringent with polarized light
Calcium oxalate
Envelope
Calcium Oxalate Crystals
Acid pH urine
Most frequently observed crystal in
urine Most common form is octahedryl shape, often referred to as an envelope shape Multicolored when polarized Normal Alkaline pH Crystals Amorphous phosphates Triple phosphate Ammonium biurate Common Crystals in Alkaline pH Amorphous phosphate
Sulfonamides Radiographic dye (contrast media) Sulfa Crystals Form varies dependent upon the type of sulfa drug administered
Other Microscopic Elements
Bacteria Yeast, mycelial elements (pseudohyphae) Fat Trichomonas vaginalis Sperm Mucus Starch, talc Fibers Glass, plastic Bacteria Most often rod-shaped Vary in size Must use high power objective Presence may indicate UTI Contamination
Bacteria Correlate with Nitrite reagent strip pH often alkaline Urea ammonia ammonia increases the pH Bacteria DO NOT make the urine alkaline Bacterial enzyme convert urea to ammonia Yeast and Mycelial Elements Budding forms or singly Ovoid and more refractile than RBC Will not lyse with acetic acid or KOH
Note pseudohyphae (mycelial
elements) Fat Highly refractile Found in 3 forms: Within fatty cast Within oval fat body Free fat droplet Fat vs Starch Both polarize light Starch has characteristic central dimples Trichomonas vaginalis Round to lemon-pear shape
Undulating membrane and flagella
provide movement Sexually transmitted Similar in size with WBC and RTE Can be confused with WBC Spermatozoa May be seen in male and female urine Usually not clinically significant unless Post vasectomy Rape Child urine Mucus Low refractive index makes it difficult to see
Wavy, delicate ribbon-like strands
or threads Can be mistaken for hyaline cast Starch, talc Contaminant Varies in size and shape Characteristic central dimple Fibers Contaminant Large, with distinct edges Misidentified as casts
