Clin Path Lab 6 Urinalysis

CLINICAL PATHOLOGY LABORATORY 6 – Urinalysis and Fecalysis

USTMED ’07 Sec C – AsM

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URINARY SEDIMENTS 1. Cells cells present in urinary sediment include WBCs, RBCs and epithelial cells. These cells can be anywhere in the urinary tract from the tubules to the urethra. Type Description Normal Clinical Values implications Red blood Uniform colorless 0-3/hpf Can originate from cells smooth any part of the biconcave disks urinary tract 7um Glomerulonephritis Trauma Systemic and renal diseases White blood cells

Spherical with dull gray color. Tend to be neutrophils. 10-12 um

0-5/hpf (M) 0-8/hpf (F)

Acute infection of kidney (pyelonephritis) Cystitis (bladder) Urethritis (urethra) Urinary tract infections

Squamous epithelial

Large, flat, irreg shaped cells that contain small central nucleus Abundant cytoplasm Cell size:23-40um Slightly larger than WBC with round central nucleus Cell size: 20 um

Few

Occur in urethra and vagina Vaginal contamination

Occasional

Transitional epithelial

Can be round or pear shaped with tail like projections

Rare

Oval fat bodies

Renal epithelial cells with lipid that are highly refractive, coarse droplets in various sizes

Negative

Originate in convoluted and collecting tubules Increased numbers indicate tubular injury and damage to epithelial BM Line urinary tract from urinary pelvis to upper portion of urethra Increased amounts indicate disease of bladder or renal pelvis Result from tubular epithelial degeneration of nephron Are associated with large amounts of protein Nephrotic syndrome

Renal epithelia

2. Casts Casts are cylindric structures formed primarily within the lumen of the distal convoluted tubule and collecting duct. The major constituent of casts is Tamm-Horsfall protein, a glycoprotein excreted by the renal tubular cells. Type Description N. Values Clinical Implications Hyaline Colorless, 0-2/lpf Can indicate mild to homogenous, severe renal disease semi-transparent when increased in numbers Can be found in healthy individuals after heavy exercise Red blood cell cast

RBCs in hyaline matrix. Extremely fragile, degenerate to granular casts

Negative

Intrinsic renal disease Acute glomerulonephritis Acute interstitial nephritis Severe nephritis

White blood cell cast

WBCs in hyaline matrix Usually neutrophils

Negative

Renal Inflammation Renal infection Pyelonephritis Chronic renal disease Acute glomerulonephritis

Renal tubular epithelial cell

Renal Tubular epithelial cells in hyaline matrix

Negative

Interstitial tubular disease Vascular disease Toxins Glomerulonephritis

Granular Cast

Waxy

Cylindroid

May be coarsely or finely granular Disintegration of cellular casts or from tubule lysosomes or protein aggregates Homogenous with well defined edges that are sharp and have blunt irregular ends Cracks on lateral edges Resemble casts but have one end that tapers to a tail

Nonpathologic (seen with Hyalin casts) – after strenuous exercise in stress Pathologic – Glomerulonephritis Pyelonephritis Negative

0-2/hpf

Tubular obstruction with prolonged stasis Called renal failure casts Severe chronic renal failure Malignant hypertension Acute renal disease Diabetes mellitus Found in conjunction with casts and have same significance

Fatty casts

Associated with oval fat bodies and urinary lipids Highly refractile, contain yellowbrown fat droplets

Negative

Seen in disorders causing lipiduria (nephritic syndrome)

Mucous threads

Long thin waxy threads, very transparent

Occasiona l

Can be found in small number in normal urine Increased numbers indicate inflammation or irritation of the urinary tract

3. Microorganisms and Parasites Type Description

Normal Values Free of bacteria in kidney and bladder

Significance

Bacteria

Color: colorless Shape: Rods or cocci may be found single or in chains

Yeast

Color: colorless cells Shape: ovoid smooth cells with doubly refractile walls Often show budding and pseudohyphae Sometimes mistaken for RBCs Oval heads with long thin tails

Negative

Can be found in both male and female urine

Male: nocturnal emission, ejaculation and disease of the genital organs Female: after coitus

Turnip shaped flagellates with three anterior flagella and one anterior flagellum Confused with WBCs Needs to be mobile for identification Ova have one flat and one round side with transparent shell. Developing larvae can be seen

Negative

Transmitted sexually, frequently infection of vagina and vulva in females In males, the organisms infects urethra

Negative

Usually found in children and in fecal contamination Female worm lays her eggs in perirectal region, and during collection they can be carried into urine specimen

Spermatozoa

Trichomonas vaginalis

Enterobius Vermicularis

Can be contamination from external sources Rapidly multiply in improper stored specimen With increased WBCs, indicative of urinary tract infection Found in urinary tract infections, especially from diabetic parents Immunosuppressed patient Skin or vaginal infection

Schistosoma Hematobium

Ovium measures 50150 um Clear and colorless with characteristic terminal spine

Negative

Inhibits veins in urinary bladder Endemic in Africa, Nile Valley and Middle East

4. Crystals Crystals are frequently found in the urine. They are formed by the precipitation of urine salts subjected o changes in pH, temperature or concentration, which affect their solubility. Crystals are identified by their appearance, solubility and pH. Type Description pH Solubility Significance Uric acid Color: yellow-brown Acid AlkaliAssociated with renal Shape: different soluble, stones, gout, high shapes, most sodium purine metabolism, common are hydroxide acute febrile diamond, rhombic conditions, chronic plates in clusters, nephritis lemon shape Calcium oxalate

Colorless Envelope with intersecting diagonal lines Birefringent

Acid/ Neutral

HClsoluble Acetic acid insoluble

Hippuric acid

Color: yellow-brown to colorless Shape: elongated prisms/plates with pyramidal ends

Acid/ Neutral

Soluble in water, alkali Insoluble in acetic acid

Sodium urate

Color: yellow to colorless Shape: needle or slender prisms in sheaves or clusters

Acid

Soluble at 60oC

Report as urate crystals No clinical significance

Color: brick-dust, yellow brown Shape: small granular pink precipitation at refrigeration Salts of Na,Ca,K,Mg Triple Colorless Phosphate Shape: three to six (ammoniumsided prisms magnesium described as phosphate) coffin-lid shaped

Acid/ Neutral

Soluble at 60oC and alkali Acetic acidinsoluble

No clinical significance

Alkaline

Soluble in dilute acetic acid

Associated with renal calculi, chronic pyelitis, enlarged prostate, urinary tract infection Found in normal urine

Amorphous phosphates

Colorless Shape: granular patches with no definite shape

Alkaline

Soluble in acetic acid Insoluble at 60oC

No clinical significance

Calcium carbonate

Colorless Shape: small dumbbells or spherical forms; can be found in granular masses or in pairs

Alkaline

Soluble in acetic acid

No clinical significance

Calcium Phosphate

Colorless Shape: long, thin prisms with one pointed and arranged as rosettes or clusters of needles Thin irregular plates that float on surface of urine

Alkaline

Soluble in acetic acid

Associated with renal calculi Can be found in normal urine

Amorphous urates

Neutral

Can be found in normal individuals after ingestion of oxalate rich food and large doses of vitamin C Associated with renal stones, diabetes mellitus, liver disease and chronic renal disease Associated with diets high in fruits and vegetables containing large quantities of benzoic acid

Ammonium Biurate

Color: yellow to brown Shape: Spherical bodies with long irregular spicules

Abnormal Crystals Cystine Colorless and refractile Shape: hexagonal with equal and unequal sides Appear single or in clusters Leucine Color: yellow to brown Shape: spheroids with radial concentric striations Highly refractile with oil-like appearance Tyrosine Color: black or yellow with presence of bilirubin Shape: highly refractile needles occurring in sheaves or clusters Cholesterol Color: transparent Shape: regular to irregular flat plates with one corner notched out, may be single or in larger #s Most often found after refrigeration Bilirubin Color: yellow to brown to reddish Shape: Granules or clusters

Sulfa

Ampicillin

Color: brown to yellow Shape: needle-like shapes seen in bundles or sheaves Stacks of wheat Colorless Shape: elongated long thin needles

Alkaline/ Neutral

Soluble in acetic acid and warming

Usually indicates old urine

Acid

Soluble in HCl, alkali, and ammonia

Amino acid crystal, inherited as a metabolic defect that prevents reabsorption of cystine

Acid

Soluble in hot acetic acid, hot alcohol and alkali

Maple syrup disease Severe liver disease

Acid

Soluble in HCl, NH4OH, dilute mineral oil

Severe liver disease and tyrosinosis

Acid/ Neutral

Soluble in chlorofor m, ether, hot alcohol Insoluble in alcohol

Excessive tissue breakdown Seen in nephritis and nephritic syndrome Lipiduria, lipidemia and lymphatic obstruction due to neoplasms

acid

Soluble in chlorofor m, acetone, acid and alkali

Obstructive jaundice Bilirubin must be present in urine

acid

Soluble in acetone

Most sulfonamide drugs are more soluble than older types

acid

Administration of large parenteral doses

Radiographic Color: hypaque media (opaque?), appear dark and thick Shape: pleomorphic needles, single or sheaves

acid

Soluble in 10% NaOH

Intravenous injection for radiography Can appear up to 3 days after injection

Hemosiderin Color: yellow to brown to red Shape: heavy large granules Prussian blue stain for iron

Acid/ alkaline

Insoluble granules

Associated with anemia and destruction of RBC

Demo Slides Pus Cells

Granular Cast

Hylaline Cast

RBCs

Squamous Cells

Uric Acid crystal

Yeast Cells