Microscopic Examination of Urine Sediment

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1

12mL

volume of urine recommended for urinalysis

2

10-15mL

volume range of urine recommended for urinalysis

3

1 mL

amount of sediment obtained

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RBCs, WBCs, and casts

components that should be counted and classified

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crystals, bacteria, and mucus

components that should be assessed qualitatively

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10 LPF or HPF

minimum fields assessed for urine components depending on specific components

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supra vital stains

used to enhance visualization

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crystal-violet and safranin (Sternheimer-Malbin)

most common supra vital stain for urine

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0.5% toluidine blue solution

distinguishes various cell components differently to help in identification

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acetic acid

brings out nuclear detail of WBCs and lyses RBCs

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Sudan III and oil red O

fat stains that identify fat inside cells or free floating; within renal cells or macrophages (oval fat bodies)

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cholesterol

does not stain and must be confirmed with polarizing microscopy

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gram stain

used to identify bacteria and yeast; rarely used in UA

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Prussian blue

stains iron in hemosiderin granules blue; can be free floating or inside cells

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Hansel stain

methylene blue and eosin-Y; for identification of eosinophils

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brightfield

most commonly used microscope technique in urinalysis

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phase-contrast

ideal for urine sediments; allows more detailed visualization of RBC morphology and translucent or low-refractive components and living cells

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polarizing

confirms presence of cholesterol; also used on crystals

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cholesterol

forms a maltese cross pattern with polarized light

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interference contrast

gives 3-D images; high cost

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cytocentrifugation

a technique used to produce permanent microscope slides of urine sediment and body fluids; produces a monolayer of sediment components

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pictures

pg 132-3. 192-210, Table 7.5 pg. 137, ph 140, 144-5

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0-3/HPF

red blood cell reference interval

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0-8/HPF

white blood cell reference interval

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0-2/LPF

hyaline cast reference interval

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few/LPF

squamous epithelial cell reference interval

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few/HPF

transitional epithelial cell reference interval

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few (0-1)/HPF

renal epithelial cell reference interval

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negative/HPF

bacteria and yeast reference interval

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non/LPF

abnormal crystal reference interval

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10x

LPF

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40x

HPF

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erythrocytes

small, biconcave disks, approximately 8um in diameter and 3um deep with no nucleus

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crenated

RBC hypertonic (concentrated) urine

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ghost cells

RBC hypotonic (dilute) urine

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hypertonic

concentrated urine

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hypotonic

dilute urine

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renal bleed

increased RBC casts and significant protein

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bleeding below kidney or contamination

increased RBCs no casts or protein

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RBCs lysed or false positive

positive strip test no RBCs seen; false positive

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vitamin C or look-alike (yeast, crystals, bubbles)

false negative RBC strip test

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neutrophils

most common WBC in blood and urine

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glitter cells

WBCs in hypotonic urine

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degenerated blebs

WBCs in hypertonic urine

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upper urinary tract infection

WBCs, WBC casts along with positive protein

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lower urinary tract infection

increased WBCs, no casts and no protein (or lower level)

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leukocyturia

increased WBCs in urine

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eosinophiluria

predictor of acute interstitial nephritis due to drug sensitivity

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Hansel stain

used to detect eosinophils

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lymphocyturia

seen in viral infections kidney transplant rejection

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histiocytes

monocytes and macrophages

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squamous epithelial cells

the most common and largest of the epithelial cells; use low power; rarely significant, usually caused by contamination

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transitional (urothelial) epithelial cells

line calyces, renal pelvis, ureters, and bladder; various size and shape; seen in UTI, urinary procedures, and carcinoma (in sheets)

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renal tubular epithelial cells

convoluted tubular and collecting duct cells enumerated; seen in acute ischemic or toxic renal tubular disease from heavy metals or drug (ahminoglycosides) toxicity

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casts

formed in distal and convoluted tubules with a core matrix of uromodulin (Tamm-Horsfall protein) secreted by renal tubular cells; seen in acidic urine

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hyaline or finely granular

types of casts that are normal in small amounts

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hyaline casts

most commonly observed casts in the urine sediment; two or few/lpf are normal; seen in excess in strenuous exercise, dehydration, fever, emotional stress, CHF, and renal disease

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waxy casts

indicates prolonged stasis (take as long as 48 hours or more to form) and tubular obstruction; believed to be advanced stages of other casts; found in chronic renal failure, acute renal disease, hypertension, and renal allograft rejection

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red blood cell casts

casts diagnostic of intrinsic renal disease; most often of glomerular origin, but may result from tubular damage; accompanied by proteinuria

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proteinuria

must accompany increased numbers or abnormal casts

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WBC cast

casts that indicates renal inflammation or infection

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granular casts

casts composed primarily of uromodulin protein; not usually clinically significant casts unless they are very broad which may indicate poor prognosis; may be formed by degradation of other cellular casts

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fatty casts

casts with oval fat bodies indicating renal tubular death; signify a severe renal pathological condition, accompanied by significant proteinuria

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casts

must be correlated with chemical tests

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mucous threads, fibers, and crystals

three cast look-alikes

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crystals

result of precipitation of urine solutes, not usually present in freshly voided urine; significant in fresh voided indicates tubular damage

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concentration of urine, urine pH, and slow flow of urine

factors influencing crystal formation

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amorphous urates, acid urates, monosodium urate, uric acid, calcium oxalate

crystals present in acidic urine

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amorphous phosphates, triple phosphate, calcium and magnesium phosphates, ammonium bitrate, calcium carbonate

crystals present in alkaline urine

70

bilirubin, cystine, tyrosine and leucine, cholesterol

crystals present in metabolic conditions

71

drug crystals, bacteria, yeast, trichomonads, Gardnerella, parasites, fat, lipidemia, mucus, hemosiderin, sperm

crystals present in iatrogenic origin

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1

2

73

amorphous urate crystals

present in urine 5.7-7.0; have no clinical significance; may appear as brick dust due to uroerythrin

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acid urate crystals

sodium, potassium, and ammonium salts of urine acid that appear as small yellow-brown balls or spheres; no clinical significance

75

uric acid crystals

occur in many forms, most common is rhombic or diamond shape, also cubes, barrels, or bands and can form rosettes; appear only when urine pH is less than 5.7; commonly seen in gout or after cytotoxic drug administration

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monosodium urate crystals

appear as colorless to light-yellow slender, pencil-like prisms; no clinical significance

77

calcium oxalate crystals

most frequently observed crystals in human urine; form at any pH, commonly formed in high ascorbic acid diets or during refrigeration; seen in ethylene glycol (antifreeze ingestion) and during severe chronic renal disease; envelope crystals

78

amorphous phosphates

found in alkaline and neutral urine; indistinguishable from amorphous urates; precipitate appears white or gray; no clinical significance

79

triple phosphate

colorless and appear in different forms; most common is coffin lid; found in alkaline or neutral urine; little clinical significance, but found in conjunction with UTIs

80

calcium and magnesium phasphates

common and have no clinical significance; found in neutral and slightly alkaline (sometimes slightly acidic) urine

81

ammonium biurate

thorny apple appearance (yellow brown spheres with striations on surface); normal urine solute seen after storage; significant in fresh urine indicating renal tubular damage

82

calcium carbonate

appear as tiny, colorless granular crystals usually found in pairs or tetrads; no frequently found and no clinical significance

83

bilirubin crystals

indicate large amounts of bilirubin in the urine; only form in acidic urine; appear as small clusters of fine needles

84

cystine

colorless, hexagonal plates with uneven sides; present primarily in acidic urine; clinically significant indicating disease (hereditary cystinosis or cystinuria);

85

tyrosine and leucine

form in acidic urine and dissolve in alkaline urine; rarely seen but indicate abnormal process such as severe liver disease or a rare inherited metabolic disorder

86

cholesterol

clear, thin parallelogram plates with notched corners; indicate large amounts of cholesterol and ideal conditions that allowed them to precipitate out into the urine; usually accompany oval fat bodies, fatty casts, and large amounts of protein; signify nephrotic syndrome, kidney disease

87

iatrogenic crystals

form due to treatment administered such as drugs, dyes, contrast media

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rod-shaped bacili

most common bacteria in urine

89

bacteria

presence indicates UTI (accompanied by leukocytes) or contamination; reported as few, moderate, or many per HPF

90

yeast

colorless ovoid cells resembling RBCs; seen often as vaginal contaminant

91

KOH prep

prepared to view yeast

92

Trichomonads vaginalis

most common cause of parasitic gynecologic infection in females as an STD; turnip-shaped flagellates and have jerky motility in wet preps; reported as present

93

Gardnerella vaginalis

an anaerobic bacterium; clue cells present; characteristic of bacterial vaginosis

94

clue cells

squamous epithelial cells from the vaginal mucosa with large numbers of bacteria adhering to them

95

parasites

common are Enterobius vermicularis (pinworm), Giardia lamblia and Schistosoma haematobium (schistosomiasis)

96

mucus

a protein produced by the renal tubular epithelium; no clinical significance

97

fat

found in urine in three forms; free-floating droplets, oval fat bodies, or within fatty casts; triglycerides and/or cholesterol

98

triglycerides

will stain with Sudan III or an oil red O stain

99

cholesterol

will not stain, but will demonstrate birefringence with polarizing microscopy

100

cholesterol droplets

produce a distinctive maltese cross pattern

101

lipiduria

always clinically significant; present in a variety of renal diseases and may occur after severe crush injuries; always accompanied by proteinuria

102

hemosiderin

form of iron that results in ferritin denaturation; may be seen in urine after a severe hemolytic episode (transfusion reaction); Prussian blue used to identify

103

sperm

indicates ejaculation or recent sexual intercourse

104

fibers

hair, cotton, fabric threads, diapers and hygiene products often appear in urine sediment

105

starch

originate from body powders or gloves; not perfectly round with a centrally located dimple; exhibits pseudo-maltese pattern with polarized microscopy

106

fecal matter

come from improper collection or through abnormal connection between urinary tract and the bowel

107

correlation

process of using entire analysis: physical, chemical, and microscopic

108

disease process, functional change, hereditary disease, or iatrogenic agent

purposes of findings in urine sediment