Microscopic Examination of Urine

The microscopic examination of urine is of vital importance in determining the correctness of diagnosis of a renal system infection and disease. Specimen must be fresh and concentrated for more accurate results. First morning specimen is preferable. Proper urine collection is also necessary as well as proper techniques for microscopic examination of urinary sediments for accurate results. Urinary sediments should be examined with subdued light, using the LPO before HPO. Centrifugation for 3-5 minutes at 1500-3000 rpm is advisable. Urinary sediments consist of all solid particles and formed elements in the urine Two Types of Urinary Sediments: A. Unorganized due to a change in reaction or concentration (chemical part); examples are crystals and amorphous materials B. Organized most important (biological part); include casts, RBC, pus cells, epithelial cells, microorganisms, animal parasites, spermatozoa, yeasts, and fungi Reporting: Casts specify kind per coverslip (total count in 10-20 lpf) RBC and pus cells range per hpf Epithelial cells, microorganism, crystals under HPO (specify kind and report in plus sign): rare, occasional (+/-), few (+), many (++), abundant (+++ or ++++) or TNTC (too numerous to count) Plus system for quantifying urinary sediment: + (1-10) +++ (21-30) ++ (11-20) ++++ (more than 30) ORGANIZED STRUCTURES 1. Casts: albuminous materials thought to have come from exudates from blood, pathologic secretions of renal tubules or products of degeneration. They are formed primarily within the lumen of the distal convoluted tubule and collecting duct, providing a microscopic view of conditions with the nephrons. They may be hyaline, waxy, granular, fatty, or containing organized structures (blood, pus, epithelial, or bacterial). They are cylindrical in structure because they assume the shape of the tubules as they pass through. The protein that make up the matrix of casts is called Tamm-Horsfall protein. The presence of casts in urine is referred to as cylindruria. 1.1 Hyaline: colorless, homogenous, semi-transparent cylindrical structures with parallel sides and usually rounded ends. It is the least significant of the casts. They result from the precipitation of the Tamm-Horsfall protein (a specific mucoprotein) within the lumen of the kidney. Its persistent presence is a significant sign of renal disease (nephrosclerosis). 1.2 Waxy: grayish or colorless, homogenous and more opaque and wider than hyaline casts with broken ends and fissures and cracks on their sides. They stain pale pink or dark purple with Sternheimer Malbin stain. Their presence imply renal stasis and are associated with severe renal chronic disease and renal amyloidosis 1.3 Granular: hyaline casts with numerous fine or coarse granules. If found in considerable numbers, may denote glomerulo nephritis. They are due to epithelial degeneration. 1.4 Fatty: contain numerous globules of fat or the fat may be in fine refractile granules. If found in considerable number, many denote glomerulonephritis. Granules and fat droplets within the cast are due to epithelial segmentation. 1.5 Epithelial: true hyaline casts which contain many renal epithelial cells. Its presence implies desquamation of the epithelium, which is seen in parenchymatous inflammation. When the casts are well-preserved, they indicate active acute nephritis.

1.6 Blood: contain a large number of erythrocytes, which are degenerated. They indicate hemorrhage in the renal tubules, which is common in acute nephritis. 1.7 Pus: contain large number in the kidney, usually pyclonephritis 1.8 Bacterial: they are rare and their presence indicate a septic condition in the kidney Structures mistaken for casts: Mucus threads Cylindroids Masses of urates, phosphates, or minute crystals

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Mucus threads: long, narrow, waxy strands or ribbon-like from the mucus surfaces; often appear with split ends and curved but never rounded; abundant if calcium oxalate crystals are present Cylindroids: resemble hyaline casts in appearance except that they taper off to a fine filament; usually found together with hyaline casts esp. in cases of circulatory disturbances and irritation of the kidneys Masses of urates, phosphates, or crystals: accidentally take a cylindrical appearance and to distinguish them from casts, gentle heating or addition of certain chemicals will help

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Epithelial cells: microscopic examination of urine can reveal three epithelia cell types squamous, transitional, and renal. 2.1 Squamous: large flat cells with a large central nucleus found in the urethra or vagina. Least significant of the epithelial cells. Normally present in the urine of woman. 2.2 Transitional: caudate and pear-shaped with a central nucleus lining the renal pelvis and bladder; also called tail cells 2.3 Renal: small, round, mononucleated cells larger than pus cells; most significant of the epithelial cells; implies destruction of renal tubules (tubular necrosis); seen in glomerulonephritis, nephrosis, hemolytic anemias and hemochromatosis

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Pus cells (leukocytes): these are granular spherical cells similar blood WBC; they are the scavengers of the body frequently leaving blood vessels in search of bacteria and cellular debris. Their granules are partly neutrophilic and partly products of degeneration. When abundantly present in urine, there is usually an increase in the amount of albumin. Its presence in urine is known as pyuria and indicates chronic cystitis (suppuration in some parts of the urinary tract such as bladder, urethra or renal pelvis) Erythrocytes: are refractile (shiny) biconcave disks resembling tiny buttons, slightly thinner in the center than around the edge; they do not have nuclei. Urine containing blood is always albuminous. Large amounts of blood from the kidneys give it a brown smoky appearance. Any abnormal increase in red blood cells in urine is called hematuria. A positive blood result in the chemical analysis with the presence of intact RBC is due to hematuria; the absence of erythrocytes with a positive blood result in the chemical analysis may be due to hemoglobin or myoglobin. In very dilute urines, the cells swell losing their biconcave appearance. Some of the lyse (rupture) realeasing hemoglobin and appear as faint colorless circles known as shadow or ghost cells. In concentrated urine, red cells appear collapsed (crenated) having lost some of their intracellular fluid.

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Spermatozoa/ Sperm cells: have spherical heads and long thin tails; frequently present in urine of male patients after nocturnal emissions and in both sexes after coitus Bacteria: very small organisms appearing to vibrate due to this type of motility called Brownian movement caused by the bombardment of water molecules against the organism. Not normally

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present in urine but may be a contaminant in passing out through the urethra. They produce a uniform cloudiness, which will not clear on filtration. Bacilli E. coli, P. vulgaris, P. aeruginosa, S. typhosa, TB; Cocci Staphylococci and Streptococci 7. Animal parasites: T. vaginalis (protozoa), S. hematobium, and T. vaginalis (flagella), motile and when present, it is usually a contaminant from the vagina or a result of urethral infection in males. S. hematobium ovum may be seen in urine which is bloody in nature Yeast cells: characteristically show budding; small and round frequently found as a urine contaminant of women with Candida albicans infection of the vagina. It may also indicate presence of sugar in urine Fungi/ Mold: rarely found in urine but when present is identified by refractile, jointed, or branched rods (hyphae)

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10. Extraneous structures/ artifacts: due to contamination 10.1 Diatoms: unicellular microscopic algae from tap water and belonging to plant kingdom 10.2 Air bubbles: look like fat globules or some of the crystals 10.3 Starch granules: spherical with concentric striations; to confirm, add iodine and a blue color will develop if it is starch 10.4 Fibers from clothing, cotton, tissue paper 10.5 Talc 10.6 Fecal materials UNORGANIZED STRUCTURES Normal crystals and amorphous material in acid urine: Uric acid Calcium sulfate Calcium oxalate Sodium urates Amorphous urates Normal crystals and amorphous materials in alkaline urine: Amorphous phosphates Ammonium biurates Triple phosphate Calcium carbonate Calcium phosphate Abnormal crystals (acid urine): indicates abnormal metabolism Cystine Cholesterol Tyrosine Hippuric acid Leucine Sulfa crystals 1. Amorphous urates/phosphates: brick-red dust granules or deposits dissolved by heat and NaOH or HAc; no clinical significance Sodium urates: peacock-tail-like looking crystals arranged in fan sheaf-like or leaf-like structures Uric acid: yellowish-brown whetstone-shaped or rhombic plates or rosettes or lemon-shaped crystals; dissolve when heated with NaOH Calcium oxalate/carbonate: colorless envelope-shaped or dumbbell shaped crystals; appear in urine after ingestion of large amounts of substances rich in oxalic acid like tomatoes, berries and asparagus. Its clinical significance lies in its tendency to produce calculi. Calcium phosphates: large forms, thin irregular usually granular colorless plates; sometimes called magnesium phosphates

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Ammonium biurates: yellow spherical bodies with radial or concentric striations and long prismatic spicules; known as thorn-apple looking elements Triple phosphates: ammonium-magnesium phosphate crystals with characteristic coffin-lid shape Calcium sulfate: long colorless, needle-like crystals or long prismatic tables; cigarette-butt looking crystals Cysteine: colorless refractile hexagonal plates or quadrilateral prisms soluble in HCl but not in HAc; gives red color to Sullivan test

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10. Tyrosine: fine needles in cluster or sheaves which may appear black in the center; occur together with leucine in acute yellow atrophy and destructive diseases of the liver; gives green color to Morner reagent 11. Leucine: yellow oily-looking crystal; spherical with radial or concentric striations; associated with liver disease like tyrosine; gives blue color to Salkowski s test 12. Cholesterol: large flat hexagonal plates with one or more corners cut off or notched out; may occur in nephritis conditions 13. Hippuric acid: brown needles or prisms conglomerated into masses; soluble in HAc. 14. Sulfa crystals: Sulfanilamide Sulfa pyridine Sulfachiazole

Sulfadiazine (chestnut burr forms) Sulfa guanidine Sulfamethylthiazole