Examination of Urine Sediment

Centrifuged urine sediment should contain all the insoluble materials (commonly referred to as formed elements) that have accumulated in the urine following glomerular filtration and during passage of fluid through the renal tubules and lower urinary tract. Cellular elements are from two sources: 1) desquamated/spontaneously exfoliated epithelial lining cells of the kidney and lower urinary tract, and 2) cells of hematogenous origin (leukocytes and erythrocytes). Normal' or reference values for formed elements will vary from one laboratory to another because of (1) the variation in concentration of random urine specimens, and (2) the different methods used to concentrate the sediment by centrifugation

Methods for Examining Urine Sediment

Recommended that examination take place when the sample is fresh,no preservative has been added, and Midstream collection is recommended for females to reduce contamination from vaginal elements. A. Brightfield Microscopy performed to a limited extent on unstained urine preparations, difficult to do the identification of leukocytes, histiocytes, epithelial cells, and cellular casts. B. Phase-Contrast Microscopy beneficial for the detection of more translucent formed elements of the urinary sediment.Its has the advantage of hardening the outlines of even the most transparent formed elements, making detection simple. Scanning time is decreased and the yield increased. C. Polarized Microscopy used to distinguish crystals and fibers from cellular or protein cast material. D. Quantitative Counts The hemocytometer is used in many labs for quantifying the elements of urine sediment. Counting cells from an unspun sample of urine in a hemocytometer has advantages : decrease in variability caused by centrifugation and suspension, a fixed volume of urine for examination, and a marked visual field for accurate counting. Kesson (1978) provided evidence that chamber counts on centrifuged urine sediments are more reliable in predicting renal functional abnormalities than is a conventional method using cells per high power field. Recovery of cells may vary depending on centrifuge speed, specific gravity, and pH.

Microscopic Components in Urine Sediment

I. Cells
Erythrocytes Under high power : pale biconcave disks that may vary somewhat in size but are usually about 7 m in diameter. not fresh specimen : appear as faint, colorless circles or shadow cells,' because the hemoglobin may dissolve out. in hypertonic urine : appear as small, rough cells with crinkled edges.

 In dilute urine : the cells will swell and rapidly lyse, releasing hemoglobin and leaving only empty cell membranes referred to as ghost cells.' Erythrocytes are found in small numbers (0-2 cells/hpf) in normal urine; more then 3 cells/hpf is considered abnormal. The presence of increased numbers of erythrocytes in the urine may indicate a variety of urinary tract and systemic conditions include: 1. 2. 3. 4. renal disease lower urinary tract disease extrarenal disease toxic reactions 5. physiologic causes Dysmorphic Erythrocytes. Red blood cells with cellular protrusions or fragmentation are termed dysmorphic and some authors have suggested that their presence in urine samples is strongly suggestive of renal glomerular bleeding Leukocytes Neutrophils : the predominant type of leukocyte (white blood cell [WBC]) that appears in the urine. Under high power, these cells appear as granular spheres about 12 m in diameter with multilobated nuclei. Nuclear segments may sometimes appear as small, round, discrete nuclei Pyuria : Increased numbers of leukocytes (principally neutrophils) in the urine is termed pyuria, and indicates the presence of infection or inflammation in the urinary tract. Eosinophils : Appropriately stained, bilobed eosinophils may be noted in patients with tubulointerstitial disease associated with hypersensitivity to drugs such as penicillin and its analogues. Lymphocytes and Mononuclear Leukocytes : When mononuclear cells (histiocytes, lymphocytes, or plasma cells) constitute 30% or more of a differential count, chronic inflammation is indicated. Many small lymphocytes may be found in urine during renal transplant rejection. Epithelial Cells Squamous Epithelial Cells : the most frequent epithelial cell seen in normal urine. When stained with crystal-violet safranin, nuclei are purple and cytoplasm pink to violet Transitional (Urothelial) Epithelial Cells : Transitional epithelial cells line the urinary tract from the renal pelvis to the lower third of the urethra. When stained, transitional cells have dark blue nuclei with variable amounts of pale blue cytoplasm Renal Tubular Epithelial Cells : the most significant types of epithelial cells found in urine because the finding of an increased number indicates tubular damage

II.

Casts

the only formed elements of urine that have the kidney as their sole site of origin. In the normal person, very few casts are seen in the urinary sediment. In kidney
diseases, they may appear in large numbers and in many forms. Increased numbers of casts usually indicate that kidney disease is widespread and that many nephrons are involved. Large numbers of casts may also be seen in healthy persons after strenuous exercise accompanied by proteinuria.

Cast formation increases with lower pH, increased ionic concentration, and when there is stasis or obstruction of the nephron by cells or cell debris. It is also increased when larger than normal amounts of plasma proteins enter the tubules. Classification of cast i. Cast Matrix a. Hyaline Casts : translucent with brightfield microscopy, pink with supravital staining. Increased numbers are seen with renal diseases and transiently with exercise, heat exposure, dehydration, fever, congestive heart failure, and diuretic therapy. b. Waxy Casts : With chronic renal diseases, some casts become denser in appearance and are known as waxy. With brightfield microscopy, waxy casts are homogeneously smooth in appearance with sharp margins, blunted ends, and cracks or convolutions frequently seen along the lateral margins, indicating a measure of brittleness. Cellular Casts a. Erythrocyte (Red Blood Cell) Casts : appear yellow under the low-power objectives. Pathologic disorders in which erythrocyte casts appear in the sediment include many acute glomerulonephritides, IgA nephropathy, lupus nephritis, subacute bacterial endocarditis, and renal infarction. b. Leukocyte (White Blood Cell) Casts : are refractile, exhibit granules, and frequently multilobated nuclei will be visible unless disintegration has begun. The most common disease of this category is pyelonephritis, glomerular disease owing to the chemotactic effect of complement, nephritis, lupus nephritis, and even in the nephrotic syndrome. c. Renal Tubular Epithelial Cell Casts : are seen in urine with acute tubular necrosis, viral disease (e.g., cytomegalovirus disease), or exposure to a variety of drugs. d. Mixed cellular Casts : Not infrequently, two distinct cell types may be present within a single cast. This has been referred to as a mixed cast, and examples might include leukocyte/renal, erythrocyte/leukocyte, and eosinophil/renal.When the cell types cannot be established with certainty, the resulting cast is known as a cellular cast. Inclusion Casts a. Granular Casts. : may originate from plasma protein aggregates that pass into the tubules from damaged glomeruli, as well as from cellular remnants of leukocytes, erythrocytes, or damaged renal tubular cells. b. Fatty Casts : These are commonly seen when there is heavy proteinuria and are a feature of nephrotic syndrome c. Crystal Casts.: Casts containing urates, calcium oxalate, and sulfonamides (sulfamethoxazole) are occasionally seen. These casts indicate deposition of crystals in the tubule or collecting duct.. Pigmented Casts a. Hemoglobin (Blood) Casts: appear yellow to red, although sometimes the color is quite pale. Most are seen with erythrocyte casts and glomerular disease. Less commonly, seen with tubular bleeding and rarely with hemoglobinuria. b. Hemosiderin Casts: derive from pigment-laden renal tubular cells. c. Myoglobin Casts. : red-brown in color and occur with myoglobinuria. associated with acute renal failure. d. Bilirubin and Other Drug Casts : seen in urine when there is obstructive jaundice, and will color casts a deep yellow brown. Drugs, such as

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phenazopyridine (Pyridium), cause a bright yellow to orange color in acid urine and will color casts and cells. Broad Casts Defined as those with a diameter two to six times that of normal casts. Indicate tubular dilation and/or stasis in the distal collecting duct. Other Miscellaneous Casts or Cast-Like Structures Bacteria may become embedded in cast matrices, and on supravital staining, they appear dark purple with a pale pink matrix. Mucous threads are commonly confused with casts. However, these are larger, long, and ribbon-like, with poorly defined edges and pointed or split ends, in contradistinction to casts that tend to have well-defined edges and blunt ends.

III.

Crystals

Crystals form by the precipitation of urinary salts when alterations in multiple factors affect their solubilities. These include changes in pH, temperature, and concentration Many of the commonly seen crystals have characteristic morphologies; however, variability does exist, sometimes leading to confusion between pathologic and nonpathologic crystal structures -Crystals Found in Normal Acid Urine Amorphous Urates (Calcium, Magnesium, Sodium, and Potassium Urates). Crystalline Urates (Sodium, Potassium, and Ammonium). Crystalline Uric Acid. Calcium Oxalates. -Crystals Found in Normal Alkaline Urine Amorphous Phosphates (Calcium and Magnesium). Crystalline Phosphates. Calcium Carbonate. Ammonium Biurate. -Crystals Found in Abnormal Urine Cystine. Tyrosine. Leucine. -Sulfonamide (Sulfadiazine) Crystals. -Ampicillin(HighDosage). -Radiographic Media (Meglumine Diatrizoate). -Other Drugs. Several drugs have been reported to cause crystalluria when administered in highdosage schedules or following overdose. Examples include high-dosage 6-mercaptopurine therapy, primidone overdosage, and dihydroxyadenine from massive blood transfusion. -Abnormal Cells and Other Formed Elements Tumor Cells. Viral Inclusion Cells. Platelets. Bacteria. Fungi. Parasites. -Contaminants and Artifacts