urine sediments

Sediment constituents

LACASANDILE, RUSSEL M.

BMLS – III - 1

RED BLOOD CELLS CHARACTERISTICS

Smooth Non-nucleated Biconcave disks like

(7 mm - diameter) Identified using High

Power Objective Ave. # seen in 20 hpfs

CLINICAL SIGNIFICANCE Hyposthenuria Glomerular membrane

damage Vascular damage

(genitourinary tract) Hematuria

RED BLOOD CELLS

RED BLOOD CELLS

Frequently confused with yeast cells, oil droplets and air bubbles.

WHITE BLOOD CELLS CHARACTERISTICS

Larger than RBC (diameter – 12mm)

Nuetrophil – predominantly found in the urine sediment

Ave. # seen in 10 hpfs

CLINICAL SIGNIFICANCE Presence of Eosinophil

Drug-induced interstitial nephritis

Urinary Tract Infection Renal Transplant

rejection pyuria Presence of an infection

or inflammation in the genitourinary system

WHITE BLOOD CELLS

WHITE BLOOD CELLS

EPITHELIAL CELLS CHARACTERISTICS

Derived from the lining of the gastrourinary system

3 types Squamous EC Transitional EC Renal tubular EC

EPITHELIAL CELLS Squamous Epithelial

Cell Largest cells found in the

urine Contains abundant and

irregular cytoplasm and prominent nucleus like an RBC size

Often first structures observed when the sediment under LPO

Uses LPO and HPO magnification

Commonly reported as rare, few, moderate or many

Appear folded, possible resembling cast and will begin to disintegrate in urine that is not fresh

Originate – linings of the vagina and female urethra and lower portion of the male urethra

SQUAMOUS EPITHELIAL CELLS

Variation – clue cell (indicative of vaginal

infection by Gardnerella vaginalis)

Bacteria should most covered of e cell surface

CLINICAL SIGNIFICANCE Perineal or vaginal

contamination (female) Foreskin contamination

(males)

SQUAMOUS EPITHELIAL CELLS

SQUAMOUS EPITHELIAL CELLS

SQUAMOUS EPITHELIAL CELLS

EPITHELIAL CELLS Transitional Epithelial

Cells Smaller than squamous

cells Appear

Spherical Polyhedral Caudate

Uses HPO Reported as rare, few,

moderate or many

Originate – lining of renal pelvis Calyces Ureters Bladder Portion of the male

urethra

TRANSITIONAL EPITHELIAL CELLS

CLINICAL SIGNIFICANCE Malignancy Viral infection

TRANSITIONAL EPITHELIAL CELLS

EPITHELIAL CELLS Renal Tubular

Epithelial Cells vary in shape and size Proximal CT RTE

Larger Rectangular Referred as

columnar or convoluted cells

Distal CT RTE Smaller Round and oval Mistaken as WBC’s

and Spherical Transitional EC

Collecting Duct RTE Cuboidal Presence of at least

one straight edge

RENAL TUBULAR EPITHELIAL CELLS

Collecting Duct RTE Appear in groups

(renal fragments) Identified in HPO Reported as rare, few,

moderate or many

CLINICAL SIGNIFICANCE Tubular injury Necrosis of renal

tubules Pyelonephritis Salicylate intoxication Transplant rejection

RENAL TUBULAR EPITHELIAL CELLS

RENAL TUBULAR EPITHELIAL CELLS

EPITHELIAL CELLS Oval Fat Bodies

Lipid containing RTE cells

Usually seen in conjunction with free-floating fat droplets

Presence is confirmed by staining the sediments using Sudan III or Oil Red O fat stains and examing the sediment using polarized microscopy

CLINICAL SIGNIFICANCE Lipiduria Severe tubular

necrosis DM Trauma

OVAL FAT BODIES

OVAL FAT BODIES

BACTERIA CHARACTERISTICS

Not normally present Contaminant bacteria

multiply rapidly at room temperature for extended periods

Results in a pH of 8 and positive nitrite test (unacceptable)

Appear Spherical (cocci) Rods (rods)

Reported using HPO Reported in terms of few,

moderate or many Phase microscopy aids in

the visualization

BACTERIA CLINICAL

SIGNIFICANCE UTI

YEAST CHARACTERISTI

CS Appear

Small Refractile oval

structures (w/ or w/o bud)

Reported as rare, few, moderate or many per hpf

Candida albicans Yeast cell (seen in

urine of: Diabetic Immunocomprom

ised patients women

With vaginal moniliasis

YEAST CLINICAL

SIGNIFICANCE Diabetes Vaginal moniliasis infection

YEAST

PARASITES CHARACTERISTICS

Trichomonas vaginalis Most frequently

encountered Trophozoite –

flagellate with an undulating membrane

Rapid darting movement in in Wet preparations (identification)

Reported as rare, few, moderate or many per hpf

May resemble a WBC Transitional RTE cell

Phase microscopy enhance visualization of flagella or undulating membrane

PARASITES Schistisoma

haematobium Bladder parasite Ova (appear in the

urine) Feacal contamination –

can cause of ova fom intestinal parasites

Ova from pinworm (Enterobius vermicularis) Most common

contaminant

CLINICAL SIGNIFICANCE Vaginal inflammation Urethral infection Prostrate infection

PARASITES

SPERMATOZOA CHARACTERISTICS

Oval, slightly tapered heads

Long flagella-like tails Motile

CLINICAL SIGNIFICANCE Male infertility Retrograde ejaculation

SPERMATOZOA

MUCUS CHARACTERISTICS

Protein material produced by the glands and epithelial cells of the lower genitourinary tract and RTE cells.

Tamm-horsfall protein Major constituent of

mucus

Appears microscopically as thread-like structures with a low refractive index

Reported as rare, few, moderate or many per lpf

More frequently present in female urine specimens

MUCUS

CAST CHARACTERISTICS

Only elements found in the urinary sediment

Found within the lumens of the tubules and collecting duct

Detection: LPF Identification: HPF Reporting: average

number/ 10 lpfs Dissolves quickly in

dilute, alkaline

Cast Composition Major constituent:

Tamm-Horsfall protein glycoprotein excreted

by the RTE cells of the distal convoluted tubules and upper collecting ducts

Other proteins: albumin immunoglobulins

CAST Cast Formation1. Aggregation of Tamm-

Horsfall protein into individual protein fibrils attached to the RTE cells

2. Interweaving of protein fibrils to form a loose fibrillar network (urinary constituents may become enmeshed in the network at this time)

3. Further protein fibril interweaving to form a structure4. Possible attachment of

urinary constituents to the solid matrix

5. Detachment of protein fibrils from the epithelial cells

6. Excretion of the cast Cylindruria- presence

of urinary casts

CAST Hyaline Casts

Most frequently seen cast

Consist of Tamm-horsfall protein

0-2 per lp Colorless (unstained) Easily overlooked

(subdued light) f (normal)

Increased: Strenuous exercise Dehydration Heat exposure

Emotional stress Acute glomerular

nephritis Pyelonephritis Chronic renal disease Congestive heart

failure

HYALINE CASTS

HYALINE CASTS

HYALINE CASTS

CASTS RBC Casts

Indicates bleeding (gastrourinary tract and nephron

Detection: LPO Fragile Fragments: more

irregular in shape Ages Color: Orange-red

CLINICAL SIGNIFICANCE Glomerulonephritis Proteinuria Dysmorphic

erythrocytes Strenuous exercise

RBC CASTS

RBC CASTS

RBC CASTS

CASTS WBC Cast

Signifies infection or inflammation (nephron)

Detection: LPO Appear granular Nucleus: multilobed Forms clumps

CLINICAL SIGNIFICANCE Pyelonephritis Acute interstitial

nephritis Inflammation

WBC CASTS

WBC CASTS

CASTS Bacterial Casts

Bacilli bound to protein

May be mixed with WBC

CLINICAL SIGNIFICANCE

Pyelonephritis

BACTERIAL CASTS

EPITHELIAL CELL CASTS CHARACTERISTICS

Associated with heavy metal and chemical or drug-induces toxicity, viral infection and allograft rejection

DCT Cells: Smaller Round/oval

CLINICAL SIGNIFICANCE Tubular destruction Drug-induced toxicity Viral infection Allograft rejection Renal tubular damage

EPITHELIAL CELL CASTS

EPITHELIAL CELL CASTS

FATTY CASTS CHARACTERISTICS

Seen in conjunction with oval fat bodies and free fat droplets

Highly refractile under bright-field microscopy

May contain few/many fat droplets

Confirmation: polarized microscopy and Sudan III or Oil Red O fat stains

CLINICAL SIGNIFICANCE Nephrotic syndrome Tubular necrosis Diabetis mellitus Crush injuries

FATTY CASTS

FATTY CASTS

MIXED CELLURAL CASTS

CHARACTERISTICS Most frequently

encountered include RBC and WBC

CLINICAL SIGNIFICANCE Glomerulonephritis Pyelonephritis

MIXED CELLURAL CASTS

MIXED CELLURAL CASTS

MIXED CELLURAL CASTS

GRANULAR CASTS CHARACTERISTICS

Coarse or Fine Pathologic or

Nonpathologic (origin) Lysosomes

excreated by RTE Granules represent

disintegration of cellular casts and tubule cell or protein aggragates filtered by the glomerulus

Visualized under low-power microscopy

Final Identification: high power

Cast matrix: waxy appearance

Structure: more rigid, jagged or broken and diameter becomes broader

GRANULAR CASTS CLINICAL

SIGNIFICANCE Strenuous exercise Pyelonephritis Glomerulonephritis

GRANULAR CASTS

GRANULAR CASTS

WAXY CASTS CHARACTERISTICS

Representative of extreme urine stasis

More easily visualized than hyaline casts because of higher refractive index

Supervital stain: they stain homogeneous, dark pink

CLINICAL SIGNIFICANCE Chronic renal failure Stasis of urine flow

WAXY CASTS

WAXY CASTS

BROAD CASTS CHARACTERISITCS

Renal failure casts Represent urine stasis Granular and waxy

Most common broad cast

CLINICAL SIGNIFICANCE Destruction of tubular

walls Rena failure Extreme urine stasis

BROAD CASTS

BROAD CASTS

URINARY CRYSTALS CHARACTERISTICS

Crystals found in normal urine

Crystals found in abnormal urine

liver disease inborn errors of

metabolism renal damage

Reporting: rare, few, moderate,

or many/ hpf Average/ lpf

(Abnormal crystals)

URINARY CRYSTALS Precipitation of urine

solutes inorganic salts,

organic compounds, and medications (iatrogenic compounds)

subject to changes in temperature, solute concentration, and pH

Low temperatures/ref temp majority of crystal

formation takes place Presence of crystals in

freshly voided urine associated with

concentrated (high specific gravity) specimens

URINARY CRYSTALS Acidic pH

organic and iatrogenic compounds readily precipitates

*** All abnormal crystals are found in acidic urine

Neutral and alkaline pH inorganic salts

Calcium oxalate precipitates in both

acidic and neutral urine

NORMAL CRYSTALS SEEN IN ACIDIC URINE

NORMAL CRYSTALS SEEN IN ACIDIC URINE

ABNORMAL CRYSTALS SEEN IN ACIDIC URINE

Cystine Crystals found in the urine of

persons who inherit a metabolic disorder that prevents reabsorption of cystine by the renal tubules (cystinuria)

Persons with cystinuria have a tendency to form renal calculi, particularly at an early age.

ABNORMAL CRYSTALS SEEN IN ACIDIC URINE

ABNORMAL CRYSTALS SEEN IN ACIDIC URINE

Cholesterol Crystals associated with

disorders producing lipiduria, such as the nephrotic syndrome

seen in conjunction with fatty casts and oval fat bodies.

ABNORMAL CRYSTALS SEEN IN ACIDIC URINE

ABNORMAL CRYSTALS SEEN IN ACIDIC URINE

Radiographic Dye Crystals Contrast media Colorless long pointed

needles or flat rectangular plates (resemble cholesterol crystals)

Multicolored when polarized

ABNORMAL CRYSTALS SEEN IN ACIDIC URINE

ABNORMAL CRYSTALS SEEN IN ACIDIC URINE

Tyrosine crystals positive chemical test

results for bilirubin Inherited disorders of

amino-acid metabolism

ABNORMAL CRYSTALS SEEN IN ACIDIC URINE

ABNORMAL CRYSTALS SEEN IN ACIDIC URINE

Leucine crystals yellow-brown spheres

that demonstrate concentric circles and radial striations

ABNORMAL CRYSTALS SEEN IN ACIDIC URINE

Bilirubin crystals disorders that produce

renal tubular damage, such as viral hepatitis

ABNORMAL CRYSTALS SEEN IN ACIDIC URINE

Sulfonamide Crystals urine of patients

being treated for UTI due to inadequate

patient hydration appearance in fresh

urine can suggest the possibility of tubular damage if crystals are forming in the nephron

ABNORMAL CRYSTALS SEEN IN ACIDIC URINE

ABNORMAL CRYSTALS SEEN IN ACIDIC URINE

Ampicillin Crystals Following massive

doses of this penicillin compound without adequate hydration

ABNORMAL CRYSTALS SEEN IN ACIDIC URINE

ABNORMAL CRYSTALS SEEN IN ACIDIC URINE

ABNORMAL CRYSTALS SEEN IN ACIDIC URINE

URINARY SEDIMENT ARTIFACTS

Starch granule contamination may

occur when cornstarch is the powder used in powdered gloves

URINARY SEDIMENT ARTIFACTS

Oil droplets may result from

contamination by immersion oil or lotions and creams

URINARY SEDIMENT ARTIFACTS Air bubbles

occur when the specimen is placed under a cover slip

URINARY SEDIMENT ARTIFACTS

Pollen grains seasonal

contaminants that appear as spheres with a cell wall and occasional concentric circles

URINARY SEDIMENT ARTIFACTS

Hair and fibers from clothing and diapers mistaken for casts

URINARY SEDIMENT ARTIFACTS

URINARY SEDIMENT ARTIFACTS Vegetable fiber

THANKYOU!!!