1 chapter 6 urinalysis-2 professor a. s. alhomida disclaimer the texts, tables, figures and images...

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Chapter 6 Urinalysis-2

Professor A. S. Alhomida

Chapter 6 Urinalysis-2

Professor A. S. Alhomida

DisclaimerDisclaimer• The texts, tables, figures and images contained in this course The texts, tables, figures and images contained in this course

presentation (BCH 376) are not my own, they can be found on: presentation (BCH 376) are not my own, they can be found on: • References suppliedReferences supplied• Atlases orAtlases or• The webThe web

King Saud University

College of Science

Department of Biochemistry

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Examination of Urine Examination of Urine SedimentSediment

• Abnormalities in the physical and chemical portion of urinalysis play a particular role in the decision to perform a microscopic examination

• Parameters considered significant vary among Lab but include macroscopic screening

Macroscopic ScreeningMacroscopic Screening

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Examination of Urine Examination of Urine Sediment, Cont’dSediment, Cont’d

• Microscopic results should be correlated with the physical and chemical findings

• Results of Specimen don’t correclate must be rechecked for both technical and clerical errors

Correlation of ResultsCorrelation of Results

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1.1. PreservationPreservation• Cells and casts begin to disintegrate in 1 - 3 hr at room

temperature• Refrigeration for up to 48 h (little loss of cells)

2.2. Specimen ConcentrationSpecimen Concentration• Ten to twenty-fold concentration by centrifugation

General AspectsGeneral Aspects


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3.3. Types of MicroscopyTypes of Microscopy• Phase contrast microscopy• Polarized microscopy• Bright field microscopy with special staining (e.g.,

Sternheimer-Malbin stain)

General AspectsGeneral Aspects


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Examination of Urine Examination of Urine Sediment, Cont’dSediment, Cont’dMicroscopic TechniquesMicroscopic Techniques

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1.1. A sample of well-mixed urine (usually 10-15 mL) A sample of well-mixed urine (usually 10-15 mL) is centrifuged in a test tube at relatively low is centrifuged in a test tube at relatively low speed (about 2-3,000 rpm) for 5-10 minutes speed (about 2-3,000 rpm) for 5-10 minutes until a moderately cohesive button is produced until a moderately cohesive button is produced at the bottom of the tubeat the bottom of the tube

2.2. The supernate is decanted and a volume of 0.5 The supernate is decanted and a volume of 0.5 to 1.0 mL is left inside the tubeto 1.0 mL is left inside the tube

3.3. The sediment is resuspended in the remaining The sediment is resuspended in the remaining supernate by flicking the bottom of the tube supernate by flicking the bottom of the tube several timesseveral times

4.4. A drop of resuspended sediment is poured onto A drop of resuspended sediment is poured onto a glass slide and coverslippeda glass slide and coverslipped

ProcedureProcedure


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Preparing the Sediment Preparing the Sediment for Analysisfor Analysis

• Tubes, pipets and Tubes, pipets and slides used for slides used for standardizing urine standardizing urine sedimentssediments

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Preparing the Sediment Preparing the Sediment for Analysisfor Analysis

• Mix the urine well and pour Mix the urine well and pour 12 milliliters of urine in a 12 milliliters of urine in a clean centrifuge tube clean centrifuge tube

• Cap the tube and Cap the tube and centrifuge the urine for centrifuge the urine for five minutes at 450 gfive minutes at 450 g. . RPMs RPMs

• At this speed the sediment At this speed the sediment will be optimally will be optimally concentrated without concentrated without destroying any of the destroying any of the fragile elements in the fragile elements in the urineurine

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• After centrifugation, After centrifugation, remove the supernatant remove the supernatant fluid with a fluid with a polyethylene, transfer polyethylene, transfer pipet leaving 0.5 to 1.0 pipet leaving 0.5 to 1.0 mL urine on the mL urine on the sedimentsediment

• Resuspend the sediment Resuspend the sediment in the remaining urine in the remaining urine by flicking the bottom of by flicking the bottom of the tube or by running the tube or by running the tube across a test the tube across a test tube racktube rack

Preparing the Sediment Preparing the Sediment for Analysis, Cont’dfor Analysis, Cont’d

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1212


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• Using a plastic or Using a plastic or polypropylene transfer polypropylene transfer pipet, mount a drop of pipet, mount a drop of the urine in the counting the urine in the counting chamber of the chamber of the prepared commercial prepared commercial plastic slidesplastic slides

• Avoid using glass Avoid using glass pipets when mounting pipets when mounting the urine sediment as the urine sediment as elements like casts tend elements like casts tend to cling to the glass to cling to the glass surfacesurface


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• Exam the sediment Exam the sediment using the microscopeusing the microscope

• After counting the After counting the elements in the elements in the sediment, you may sediment, you may calculate the number calculate the number of elements per mL of elements per mL instead of lpf (low- or instead of lpf (low- or hight power field or hight power field or hpf), to provid hpf), to provid standardization standardization among the various among the various techniquestechniques


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1. Calculate the area of an lpf or hpf using the diameter:

2. Area =r2

3. For example: 4. r for hpf 0.35 m= 0.175 m

5. Area = 3.14 X (0.175)2 = 0.096 mm2

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6. Calculate the maximum number of lpf or hpf in the viewing area under area 22 X 22 mm for cover slip = 484 m2

7. hpf = 484 / 0.096 = 50408. Convert hpf into per mL9. 5040/ 0.02 mL X 12 = 21,000 hpf/mL

• where is 0.02 the volume of sediment and 12 is concentration factor

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• Special stains can be Special stains can be used to enhance the elements in the sediment • Sternheimer-Malbin

stain, tolui Papanicolau• Wright’s• Immunoperoxidase• Immunofluorescence dine

blue• They will enhance the

internal structures of the cells making them easier to identify

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1919


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At Low PowerAt Low Power1.1. To identify most crystals, casts, squamous To identify most crystals, casts, squamous

cells, and other large objectscells, and other large objects

2.2. The numbers of casts seen are usually reported The numbers of casts seen are usually reported as number of each type found per low power as number of each type found per low power field (LPF)field (LPF)

3.3. Example: 5-10 hyaline casts/L casts/LPFExample: 5-10 hyaline casts/L casts/LPF

4.4. Since the number of elements found in each Since the number of elements found in each field may vary considerably from one field to field may vary considerably from one field to another, several fields are averagedanother, several fields are averaged


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At High PowerAt High Power 1.1. To identify crystals, cells, and bacteriaTo identify crystals, cells, and bacteria

2.2. The various types of cells are usually The various types of cells are usually described as the number of each type described as the number of each type found per average high power field found per average high power field (HPF). Example: 1-5 WBC/HPF(HPF). Example: 1-5 WBC/HPF


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1.1. Per High Power Field (HPF) Per High Power Field (HPF) (400x)(400x)

• > 3 erythrocytes• > 5 leukocytes• > 2 renal tubular cells• > 10 bacteria

Abnormal FindingsAbnormal Findings


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2.2. Per Low Power Field (LPF) Per Low Power Field (LPF) (200x)(200x)

• > 3 hyaline casts or > 1 granular cast• > 10 squamous cells (indicative of

contaminated specimen)• Any other cast (RBCs, WBCs)



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3.3. Presence of:Presence of:• Fungal hyphae or yeast, parasite, viral

inclusions• Pathological crystals (leucine, tyrosine,

cystine)• Large number of uric acid or calcium oxalate

crystals



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Components of Components of Urine SedimentUrine Sediment

Organized ComponentsOrganized Components1.1. Red blood cellsRed blood cells

2.2. White blood cellsWhite blood cells

3.3. Epithelial cellsEpithelial cells

4.4. CastsCasts

5.5. BacteriaBacteria

6.6. YeastYeast

7.7. ParasitesParasites

8.8. SpermatozoaSpermatozoa

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Components of Components of Urine Sediment, Cont’dUrine Sediment, Cont’d

Unorganized ComponentsUnorganized Components1.1. CrystalsCrystals

• Mostly insignificantMostly insignificant• ExceptionsExceptions

• CystineCystine• Uric acidUric acid• Sulfa drug crystalsSulfa drug crystals

2.2. Chemical elementsChemical elements

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1.1. ErythrocytesErythrocytes• “Dysmorphic” vs. “normal” (> 10 per HPF)

2.2. LeukocytesLeukocytes• Neutrophils (glitter cells) More than 1 per 3 HPF• Eosinophils Hansel test (special stain)

3.3. Epithelial CellsEpithelial Cells• Renal tubular epithelial cells Few are normal• Oval fat bodies Abnormal, indicate

Nephrosis• Transitional epithelial cells Few are normal• Squamous cells Indicate level of

contamination

CellsCells


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CellsCells


1.1. Erythrocytes (GN, stone, tumor, exogenous)Erythrocytes (GN, stone, tumor, exogenous)

2.2. Renal tubular epithelial cells (many renal Renal tubular epithelial cells (many renal diseases)diseases)• Oval Fat bodies (Fat means nephrotic syndrome)Oval Fat bodies (Fat means nephrotic syndrome)

3.3. PMNs (Infection or sterile inflammation)PMNs (Infection or sterile inflammation)

4.4. Eosinophils (Some allergic interstitial Eosinophils (Some allergic interstitial nephritis)nephritis)

5.5. Squamous cells (CONTAMINATION)Squamous cells (CONTAMINATION)

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Red Blood CellsRed Blood Cells

1.1. Hematuria is the presence of abnormal numbers of red Hematuria is the presence of abnormal numbers of red cells in urine due to: glomerular damage, tumors which cells in urine due to: glomerular damage, tumors which erode the urinary tract anywhere along its length, erode the urinary tract anywhere along its length, kidney trauma, urinary tract stones, renal infarcts, kidney trauma, urinary tract stones, renal infarcts, acute tubular necrosis, upper and lower uri urinary acute tubular necrosis, upper and lower uri urinary tract infections, nephrotoxins, and physical stresstract infections, nephrotoxins, and physical stress

2.2. Red cells may also contaminate the urine from the Red cells may also contaminate the urine from the vagina in menstruating women or from trauma vagina in menstruating women or from trauma produced by bladder catherizationproduced by bladder catherization

3.3. Theoretically, no red cells should be found, but some Theoretically, no red cells should be found, but some find their way into the urine even in very healthy find their way into the urine even in very healthy individualsindividuals


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Red Blood CellsRed Blood Cells

4.4. If one or more red cells can be found in every If one or more red cells can be found in every high power field, and if contamination can be high power field, and if contamination can be ruled out, the specimen is probably abnormalruled out, the specimen is probably abnormal

5.5. RBC's may appear normally shaped, swollen by RBC's may appear normally shaped, swollen by dilute urine dilute urine ((in fact, only cell ghosts and free in fact, only cell ghosts and free hemoglobin may remainhemoglobin may remain)), or crenated by , or crenated by concentrated urineconcentrated urine

6.6. Both swollen, partly hemolyzed RBC's and Both swollen, partly hemolyzed RBC's and crenated RBC's are sometimes difficult to crenated RBC's are sometimes difficult to distinguish from WBC's in the urinedistinguish from WBC's in the urine


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Red Blood Cells, Cont’dRed Blood Cells, Cont’d

7.7. In addition, red cell ghosts may simulate yeastIn addition, red cell ghosts may simulate yeast. . The presence of dysmorphic RBC's in urine The presence of dysmorphic RBC's in urine suggests a glomerular disease such as a suggests a glomerular disease such as a glomerulonephritisglomerulonephritis

8.8. Dysmorphic RBC's have odd shapes as a Dysmorphic RBC's have odd shapes as a consequence of being distorted via passage consequence of being distorted via passage through the abnormal glomerular structurethrough the abnormal glomerular structure

9.9. Dysmorphic RBCsDysmorphic RBCsIrregular shape, size, densityIrregular shape, size, densityIndicate glomerular bleeding Indicate glomerular bleeding


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RBCsRBCs

• There are many RBCs There are many RBCs in this fieldin this field

• Note the center pallor Note the center pallor of most of the cells of most of the cells especially the one especially the one labeled with a "B"labeled with a "B"

• Can you picture the Can you picture the donut shape or donut shape or biconcave disc form of biconcave disc form of the cell? the cell?

• ““A" points to a red cell A" points to a red cell on its sideon its side


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RBCsRBCs

• This is another field of This is another field of RBCsRBCs

• Note that some of Note that some of them look granularthem look granular

• That is because they That is because they are crenated or are crenated or puckeredpuckered

• The spicules make the The spicules make the cell look granularcell look granular


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RBCsRBCs

• Note the irregular outlines Note the irregular outlines of many of these RBC's, of many of these RBC's, compared to two relatively compared to two relatively normal RBC's at the center normal RBC's at the center left of the right panelleft of the right panel. . These abnormal RBC's are These abnormal RBC's are dysmorphic RBC'sdysmorphic RBC's..

• Dysmorphic RBC's have odd shapes as a consequence of being distorted via passage through the abnormal glomerular structure


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Summary of RBCSummary of RBC


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WBCsWBCs

1.1. PyuriaPyuria refers to the presence of abnormal refers to the presence of abnormal numbers of leukocytes that may appear with numbers of leukocytes that may appear with infection in either the upper or lower urinary infection in either the upper or lower urinary tract or with acute glomerulonephritistract or with acute glomerulonephritis

2.2. Usually, the WBC's are granulocytesUsually, the WBC's are granulocytes3.3. White cells from the vagina, especially in the White cells from the vagina, especially in the

presence of vaginal and cervical infections, or presence of vaginal and cervical infections, or the external urethral meatus in men and women the external urethral meatus in men and women may contaminate the urinemay contaminate the urine


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WBCsWBCs

4.4. If two or more leukocytes per each high power If two or more leukocytes per each high power field appear in nonfield appear in non--contaminated urine, the contaminated urine, the specimen is probably abnormalspecimen is probably abnormal

5.5. Leukocytes have lobed nuclei and granular Leukocytes have lobed nuclei and granular cytoplasm cytoplasm


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WBCsWBCs

• WBC in urine are most WBC in urine are most neutrophilsneutrophils

• Like erythrocytes, WBC Like erythrocytes, WBC may lyse in very dilute may lyse in very dilute or highly alkaline or highly alkaline urine; WBC urine; WBC cytoplasmic granules cytoplasmic granules released into the urine released into the urine often resemble cocci often resemble cocci bacteriabacteria


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WBCsWBCs

• In this field, In this field, ""CC" " points points to a white cell and to a white cell and ""BB" " points to two points to two transitional epithelial transitional epithelial cellscells

• Note that you can Note that you can distinguish a nucleus in distinguish a nucleus in the white cell if you the white cell if you look very closelylook very closely

• Also note the granular Also note the granular appearanceappearance


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Summary of Summary of WBCsWBCs


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Renal Tubular Renal Tubular CellsCells

1.1. Usually larger than granulocytes, contain a Usually larger than granulocytes, contain a large round or oval nucleus and normally slough large round or oval nucleus and normally slough into the urine in small numbersinto the urine in small numbers

2. In nephrotic syndrome and in conditions leading to tubular degeneration, the number sloughed is increased

3. When lipiduria occurs, these cells contain endogenous fats. When filled with numerous fat droplets, such cells are called oval fat bodies

4. Oval fat bodies exhibit a "Maltese cross" configuration by polarized light microscopy


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Squamous CellsSquamous Cells

• This image provides a This image provides a good example of two good example of two unstained squamous unstained squamous epithelial cellsepithelial cells

• Note the size of the Note the size of the cell, its nucleus and cell, its nucleus and its irregular shapeits irregular shape

• These two cells look These two cells look somewhat granular somewhat granular which is an artifact of which is an artifact of the urine preservationthe urine preservation


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Renal Tubular Renal Tubular CellsCells

• This frame compares This frame compares a WBC ("B") and the a WBC ("B") and the renal tubular cells renal tubular cells ("A")("A")

• Note the size Note the size comparisoncomparison

• Also note how Also note how prominent the nucleus prominent the nucleus is in the renal tubular is in the renal tubular cells cells

• It is much easier to It is much easier to see than the nucleus see than the nucleus of the WBCof the WBC..


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Transitional CellsTransitional Cells

• They originate from They originate from the renal pelvis, ureter, the renal pelvis, ureter, or bladder or bladder

• It shows a transitional It shows a transitional epithelial cell at "B"epithelial cell at "B"

• The three cells just The three cells just above this one are also above this one are also transitional epithelialstransitional epithelials

• "A" points to a "A" points to a squamous epithelial squamous epithelial cellcell


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Oval Fat BodyOval Fat Body

• Oval fat bodies Oval fat bodies consist of consist of degenerated tubular degenerated tubular cells containing cells containing abundant lipid, abundant lipid, which appears which appears refractilerefractile

• Indicate heavy Indicate heavy proteinuria proteinuria


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Oval Fat BodyOval Fat Body

• Under polarized Under polarized light, oval fat light, oval fat bodies bodies demonstrate the demonstrate the ""Maltese crossMaltese cross" " appearanceappearance


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LE CellLE Cell

• Positive leukocyte esterase test results from the presence of white blood cells either as whole cells or as lysed cells.

• Pyuria can be detected even if the urine sample contains damaged or lysed WBC's.

• A negative leukocyte esterase test means that an infection is unlikely and that, without additional evidence of urinary tract infection, microscopic exam and/or urine culture need not be done to rule out significant bacteriuria


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Examination of Urine Examination of Urine Sediment, Cont’dSediment, Cont’dSummary of Epithelial CellsSummary of Epithelial Cells

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1.1. BacteriaBacteria• Bacteriuria More than 10 per HPF

2.2. YeastsYeasts• Candidiasis Most likely a contaminant

but should correlate withclinical picture

3.3. VirusesViruses• CMV inclusions Probable viral cystitis.

Bacteria and Bacteria and YeastsYeasts


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1. They are common in urine specimens because of the abundant normal microbial flora of the vagina or external urethral meatus and because of their ability to rapidly multiply in urine standing at room temperature

2. Diagnosis of bacteriuria in a case of suspected urinary tract infection requires culture

3. A colony count may also be done to see if significant numbers of bacteria are present

BacteriaBacteria


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4. More than 100,000/ml of one organism reflects significant bacteriuria

5. Multiple organisms reflect contamination. However, the presence of any organism in catheterized or suprapubic tap specimens should be considered significant

BacteriaBacteria


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BacteriaBacteria

• This is an excellent example of a mixed field of red blood cells and bacteria

• "C" is pointing to the bacteria

• Note how small they are compared to the RBC


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YeastsYeasts

1. Yeast cells may be contaminants or represent a true yeast infection

2. They are often difficult to distinguish from red cells and amorphous crystals but are distinguished by their tendency to bud

3. Most often they are Candida, which may colonize bladder, urethra, or vagina


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YeastsYeasts

• This frame shows an excellent example of yeast ("B")

• Note the budding and the more oval appearance of each cell

• "A" is a crenated red blood cell

• "C" is also a red cell


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Trichomonas Trichomonas ParasiteParasite

• Trichomonas vaginalis is the most common parasite in urine in USA and is found in approximately 25% of women in casual vaginal cervical examination.

• The presence of this organism in urine specimens of females is due to the contamination of the urine with vaginal secretions


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CytomegalovirusCytomegalovirus

• CMV is a common virus that CMV is a common virus that infects people of all ages and infects people of all ages and once CMV is in a person’s once CMV is in a person’s body, it stays there for lifebody, it stays there for life

• Most infections with CMV are Most infections with CMV are “silent,” no signs or “silent,” no signs or symptomssymptoms

• It is rarely causes serious It is rarely causes serious consequences except in consequences except in people with suppressed or people with suppressed or impaired immune systems impaired immune systems

• It is found in saliva, urine, and It is found in saliva, urine, and other bodily fluidsother bodily fluids

• Because it is often found in Because it is often found in semen as well as in cervical semen as well as in cervical secretions, the virus can be secretions, the virus can be spread by sexual contactspread by sexual contact


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Bacterial CastsBacterial CastsBacterial CastsBacterial Casts

Individual LeukocytesIndividual LeukocytesIndividual LeukocytesIndividual Leukocytes

Leukocyte CastsLeukocyte CastsLeukocyte CastsLeukocyte Casts

Individual ErythrocytesIndividual ErythrocytesIndividual ErythrocytesIndividual Erythrocytes

Erythrocyte CastsErythrocyte CastsErythrocyte CastsErythrocyte Casts

Individual BacteriaIndividual BacteriaIndividual BacteriaIndividual Bacteria

Significance of Cellular Significance of Cellular CastsCasts

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Renal Tubular Cast Renal Tubular Cast FormationFormation

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Renal Tubular Cast Renal Tubular Cast Formation, Cont’dFormation, Cont’d

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Casts, Cont’dCasts, Cont’d

1. Casts are cylinders of Tamm-Horsfall protein that solidified in distal tubules

2. Cellular casts most commonly result when disease processes such as ischemia, infarction or nephrotoxicity cause degeneration and necrosis of tubular epithelial cells

3. A common scenario is the patient with decreased renal perfusion and oliguria secondary to severe dehydration

4. Ischemic injury results in degeneration and sloughing of the epithelial cells


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5. The resulting casts often are prominent in urine produced following rehydration with fluid therapy

6. The restoration of urine flow flushes numerous casts out of the tubules

7. Leukocytes can also be incorporated into casts in cases of tubulo-interstitial inflammation (eg., pyelonephritis)

8. Red Cell - Proliferative GN or GBM defect


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9. Urinary casts are formed only in the distal convoluted tubule (DCT) or the collecting duct (distal nephron)

10. WBC - Intrarenal infection or inflammationWBC - Intrarenal infection or inflammation11. The proximal convoluted tubule (PCT) and loop of

Henle are not locations for cast formation12. Hyaline casts are composed primarily of a

mucoprotein (Tamm-Horsfall protein) secreted by tubule cells


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13.13. Even with glomerular injury causing increased Even with glomerular injury causing increased glomerular permeability to plasma proteins with glomerular permeability to plasma proteins with resulting proteinuria, most matrix or "glue" that resulting proteinuria, most matrix or "glue" that cements urinary casts together is Tamm-cements urinary casts together is Tamm-Horsfall mucoproteinHorsfall mucoprotein

14. The Tamm-Horsfall protein secretion (green dots) is illustrated in the diagram below, forming a hyaline cast in the collecting duct

15.15. Granular - Many types of renal diseaseGranular - Many types of renal disease


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16.16. Although albumin and some globulins are also Although albumin and some globulins are also incorporatedincorporated

17.17. An example of glomerular inflammation with An example of glomerular inflammation with leakage of RBC's to produce a red blood cell leakage of RBC's to produce a red blood cell cast is shown in the diagram belowcast is shown in the diagram below

18.18. Hyaline - may be normal unless numerousHyaline - may be normal unless numerous19.19. Waxy - Chronic renal diseaseWaxy - Chronic renal disease


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1. Low flow rate2. High salt concentration3. Low pH4. All of which favor protein denaturation and

precipitation, particularly that of the Tamm-Horsfall protein

5. Protein casts with long, thin tails formed at the junction of Henle's loop and the distal convoluted tubule are called cylindroids

6. Hyaline casts can be seen even in healthy patients

Factors Favoring Protein Factors Favoring Protein Cast FormationCast Formation

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TammTamm--Horsfall proteinHorsfall protein Red blood cell castRed blood cell cast


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RBCs Cast - RBCs Cast - HistologyHistology

• The presence of this red blood cell cast on urine microscopic analysis suggests a glomerular or renal tubular injury


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• This histologic section at medium power with trichrome stain highlights red blood cells grouping together in tubules to form casts

• The tubular epithelium is also damaged, with a foamy appearance, and is the basis for the appearance of oval fat bodies in urine in this case


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• Red blood cells may stick together and form red blood cell casts

• Such casts are indicative of glomerulonephritis, with leakage of RBC's from glomeruli, or severe tubular damage


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WBCs CastWBCs Cast

• White blood cell casts are most typical for acute pyelonephritis, but they may also be present with glomerulonephritis

• Their presence indicates inflammation of the kidney, because such casts will not form except in the kidney


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Tubular Epith. CastTubular Epith. Cast

• Renal Tubular Cells are originally cubic in shape; but once exfoliated, they adopt a rounded shape

• These cells are slightly larger than leukocytes (10-14 um) with lightly granular cytoplasm

• The nucleus is round, well defined and usually centric.

• The cytoplasm often shows a perinuclear halo when stained. Note the "glitter" cell (fatty degenerated WBC) in the lower-left corner


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Tubular Epith. CastTubular Epith. Cast

• This renal tubular cell cast suggests injury to the tubular epithelium


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Granular CastGranular Cast

• When cellular casts remain in the nephron for some time before they are flushed into the bladder urine, the cells may degenerate to become a coarsely granular cast

• Casts which persist may break down, so that the cells forming it are degenerated into granular debris


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• This slide shows waxy cast and granular casts

• Granular casts have a textured appearance which ranges from fine to coarse

• Since they usually form as a stage in the degeneration of cellular casts, the interpretation is similar to that for cellular casts

Granular and waxy Granular and waxy CastCast


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Waxy CastWaxy Cast

• They have a smooth consistency but are more refractile and easier to see compared to hyaline casts

• They commonly have squared off ends, as if brittle and easily broken

• They are found especially in chronic renal diseases• Diabetic nephropathy• Malignant hypertension • Glomerulonephritis


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Hyaline CastHyaline Cast

• Hyaline casts, which appear very pale and slightly refractile, are common findings in urine

• Greater numbers of hyaline casts may be seen associated with proteinuria of renal glomerular disease or extrarenal (overflow proteinuria as in myeloma)


7878

Fatty CastFatty Cast

• They are identified by the presence of refractile lipid droplets

• The background matrix of the cast may be hyaline or granular

• Interpretation of the significance of fatty casts should be based on the character of the cast matrix, rather than on the lipid content


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Summary of Urine Summary of Urine CastsCasts

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Summary of Urine Summary of Urine CastsCasts

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1.1. UrateUrate• Ammonium biurate• Uric acid

2.2. Triple PhosphateTriple Phosphate3.3. Calcium OxalateCalcium Oxalate4.4. Amino AcidsAmino Acids

• Leucine• Cystine• Tyrosine

5.5. SulfonamideSulfonamide

CrystalsCrystals


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Dihydrated Calcium Oxalate Dihydrated Calcium Oxalate CrystalsCrystals

• These are oxalate crystals

• They look like little envelopes (or tetrahedrons, depending upon your point of view)

• Oxalate crystals are common


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Monohydrated Calcium Oxalate Monohydrated Calcium Oxalate CrystalsCrystals

• Rarely found, vary in size and may have a spindle, oval, or dumbbell shape

• Appear as flat, elongated, six-sided crystals ("fence pickets")

• The arrow indicates "daughter" crystal forming on the face of a larger underlying crystal


8484

Triple Phosphate Triple Phosphate CrystalsCrystals

• Usually appear as colorless, prism-like "coffin lids"

• Often seen in urine from normal individuals.

• Can be found in urine of any pH, their formation is favored in neutral to alkaline urine

• Urinary tract infection with urease producing bacteria can promote it (and urolithiasis) by raising urine pH and increasing free ammonia


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Urate CrystalsUrate Crystals

• Uric acid crystals may appear as yellow to brown rhombic or hexagonal plates, needles or rosettes

• With rare exceptions, the finding of uric acid crystals in urine is of little clinical value


8686

Leucine CrystalsLeucine Crystals

• Leucine crystals are Leucine crystals are seen as yellow spheres seen as yellow spheres with concentric and with concentric and radial striasradial strias

• These crystals can These crystals can sometimes be sometimes be mistaken for cells, with mistaken for cells, with the center resembling the center resembling a nucleusa nucleus


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Cystine Cystine CrystalsCrystals

• These cystine crystals are shaped like stop signs

• Cystine crystals are seen as flat colorless hexagonal plates

• They often aggregate in layers, and their formation is favored in acidic urine


8888

Ammonium Biurate CrystalsAmmonium Biurate Crystals

• These crystals generally appear as yellow-brown, radially-striated spheres with irregular "thorn-apple" or "ox-horn" projections

• They may be seen in acid urine, their formation is favored in neutral to alkaline urine


8989

Cholesterol Cholesterol CrystalsCrystals

• The cholesterol crystals appear to be needle-shaped

• They are actually rectangles in cross-section

• The surrounding tissue is all necrotic (dead) debris


9090

Sulfonamide Sulfonamide CrystalsCrystals

• Sulfonamide crystals are typically yellow in color and often resemble uric acid crystals. However, sulfa crystals are easily distinguished from uric acid by confirmatory tests

• Sulfa crystals are readily soluble in acetone and exhibit a positive dextrine/sulfuric acid test ("old yellow newspaper" test)


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THE ENDTHE END

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1 chapter 6 urinalysis-2 professor a. s. alhomida disclaimer the texts, tables, figures and images...

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