Examination of Urine

Examination of Urine

Dr/Mohamed Mahmoud Nour Eldein PhD Biochemistry

Assistant Professor of BiochemistryFaculty of Medicine

Umm AL-Qura University

Urinary System

Introduction Urine is formed in the kidneys, is a product of

ultrafiltration of plasma by the renal glomeruli which is a network of arteriolar capillaries, each glomeruli is surrounded by Bowman’s capsule (a double epithelial sac) like a rounded funnel which leads to the tube.

Purpose

Urine contains important metabolic information Urine is cheap, simple, & readily available General evaluation of health Diagnosis of disease or disorders of the

kidneys or urinary tract Diagnosis of other systemic disease that affect

kidney function Monitoring of patients with diabetes Screening for drug abuse (eg. Sulfonamide or

aminoglycosides)

Collection of urine specimens

The first voided morning urine (most (most concentrated)concentrated) - qualitative

Random urine (routine) 24hrs sample- quantitative Mid-stream clean catch (MSCC) (for urine

culture)- UTI Post prandial sample-D.M

Attention Need to be examined within 1 hour

Clean CatchClean Catch

24 hour urine sample

1. For quantitative estimation of proteins

2. For estimation of vanillyl mandelic acid, 5-hydroxyindole acetic acid, metanephrines

3. For detection of AFB in urine

4. For detection of microalbuminuria

1- Macroscopic Examination Physical characteristics : color, odor, turbidity,

volume, & specific gravity− Chemical Analysis (Urine Dipstick) : pH,

glucose, protein, ketones, pus (WBC’s & bacteria), RBC’s, hemoglobin, bile

2- Microscopic Examination of urine sediment: crystals, cells, etc.

Types of AnalysisTypes of Analysis

Physical examination

Volume Color Odour Reaction or urinary pH Specific gravity

Urinary volume

The average daily urine output 1200 - 1500 mL (1.2 - 1.5 L)

The normal daily range of urine output 600 - 2000 mL (0.6 - 2.0 L)

Polyuria- >2000ml Oliguria- <400ml Anuria-complete cessation of urine(<200ml) Nocturia-excretion of urine by an adult of >500ml

with a specific gravity of <1.018 at night (characteristic of chronic glomerulonephritis)

Causes of polyuria > 2000ml

Diabetes mellitus Diabetes insipidus Polycystic kidney Chronic renal failure Diuretics Intravenous saline/glucose

Oliguria <400ml

Dehydration-vomiting, diarrhea, excessive sweating

Renal ischemia Acute tubular necrosis Obstruction to the urinary tract Acute renal failure

Urine Color and Clarity

Urine color and clarity can indicate what substances may be present in urine.

Confirmation of suspected substances is obtained during the chemical and microsopic examination.

Urine Color

Normal urine color ranges from pale yellow to deep amber — the result of a pigment called urochrome

Most changes in urine color are harmless and temporary and may be due to: Certain foods – beets may turn urine red Dyes in foods/drinks Supplements – vitamins Prescription drugs

Abnormal colors of urine & possible causes

Unusual urine color can indicate an infection or serious illness .

Colourless- dilution, diabetes mellitus, diabetes insipidus, diuretics

1. Milky- genitourinary tract infection

2. Orange-fever, excessive sweating, bilirubin

3. Red-beetroot ingestion,haematuria

4. Brown/ black- alkaptunuria, melanin Green - bile, Pseudomonas bacteria

Examples of Urine Color

Urine Clarity

Urine clarity refers to how clear the urine is. Terms used: clear, transparent, slightly cloudy,

cloudy, or turbid. “Normal” urine can be clear or cloudy. The clarity of the urine is not as important as the

substance that is causing the urine to be cloudy. Turbidity - “cloudiness” due to

particulate matter

suspended in urine

Urine Clarity

Substances that cause cloudiness but that are not considered unhealthy include: mucous, sperm and prostatic fluid, cells from the skin, normal urine crystals, and contaminants (like body lotions and powders).

Other substances that can make urine cloudy (such as red blood cells, white blood cells, or bacteria) indicate a condition that requires attention.

Examples of Urine Clarity

Odour

Normal= aromatic due to the volatile fatty acids

Standing (“old”) urine takes on an ammonia odor due to urea-splitting bacterial

Foul, offensive:Foul, offensive: Old specimen, pus or Old specimen, pus or inflammation inflammation

− Sweet: Sweet: GlucoseGlucose− Fruity: Fruity: KetonesKetones

Chemical AnalysisChemical Analysis

Urine dipsticks (Reagent Strips)

Urine dipstick are plastic strips on which are attached to a series of chemically impregnated absorbent pads, each pad contain certain chemicals that react with substance in the urine producing a color change in pad, this color change is compared with a series of known standards.

Chemical AnalysisChemical AnalysisUrine Urine

DipstickDipstickGlucoseGlucose

BilirubinBilirubin

KetonesKetones

Specific GravitySpecific Gravity

BloodBlood

pHpH

ProteinProtein

UrobilinogenUrobilinogen

NitriteNitrite

Leukocyte EsteraseLeukocyte Esterase

Reagent Strips

Procedure Reagent strips are used only once and discarded. Testing

Perform within 1 hour after collection Allow refrigerated specimens to return to room temperature. Dip strip briefly, but completely into well mixed, room

temperature urine sample. Withdraw strip. Blot briefly on its side. Keep the strip flat, read results at the appropriate times by

comparing the color to the appropriate color on the chart provided.

Procedure

Instruments are available which detect color changes electronically and prints out results

Handling and Storage of Strips Handling and Storage

Keep strips in original container Do not touch reagent pad areas Reagents and strips must be stored properly to

retain activity Protect from moisture and volatile fumes Stored at room temperature

Use before expiration date

Sources of Error

Timing - Failure to observe color changes at appropriate time intervals may cause inaccurate results.

Lighting - Observe color changes and color charts under good lighting.

QC - Reagent strips should be tested with positive controls on each day of use to ensure proper reactivity.

Sample - Proper collection and storage of urine is necessary to insure preservation of chemical.

Sources of Error

Testing cold specimens - would result in a slowing down of reactions; test specimens when fresh or bring them to RT before testing

Inadequate mixing of specimen - could result in false reduced or negative reactions to blood and leukocyte tests; mix specimens well before dipping

Over-dipping of reagent strip - will result in leaching of reagents out of pads; briefly, but completely dip the reagent strip into the urine

NegativeNegativeNegativeNegative

Trace (100 mg/dL)Trace (100 mg/dL)Trace (100 mg/dL)Trace (100 mg/dL)

+ (250 mg/dL)+ (250 mg/dL)+ (250 mg/dL)+ (250 mg/dL)

++ (500 mg/dL)++ (500 mg/dL)++ (500 mg/dL)++ (500 mg/dL)

+++ (1000 mg/dL)+++ (1000 mg/dL)+++ (1000 mg/dL)+++ (1000 mg/dL)

++++ (2000+ mg/dL)++++ (2000+ mg/dL)++++ (2000+ mg/dL)++++ (2000+ mg/dL)

The Urine The Urine Dipstick:Dipstick: GlucosGlucos

ee

Glucose + 2 HGlucose + 2 H22OO + O+ O22 --->--->Gluconic Acid + 2 HGluconic Acid + 2 H22OO22

Glucose OxidaseGlucose Oxidase

3 H3 H22OO22 + KI + KI --->---> KIO KIO3 3 + 3 H+ 3 H22OO

Horseradish PeroxidaseHorseradish Peroxidase

Chemical PrincipleChemical Principle

Read at 30 secondsRead at 30 secondsRR: NegativeRR: Negative

Significance Diabetes mellitus. Renal glycosuria.

Limitations Interference: reducing agents, ketones. Only measures glucose and not other sugars. Renal threshold must be passed in order for glucose to spill

into the urine.

Other Tests CuSO4 test for reducing sugars.

Uses and Limitations of Urine Glucose Uses and Limitations of Urine Glucose DetectionDetection

++++

++

tracetrace

400400 600600 800800 10001000200200

Uri

naly

sis

Glu

cose R

esu

ltU

rin

aly

sis

Glu

cose R

esu

ltU

rin

aly

sis

Glu

cose R

esu

ltU

rin

aly

sis

Glu

cose R

esu

lt

Blood Glucose (mg/dL)Blood Glucose (mg/dL)Blood Glucose (mg/dL)Blood Glucose (mg/dL)

Urine versus Blood GlucoseUrine versus Blood Glucose

NegativeNegative


+ (weak)+ (weak)+ (weak)+ (weak)

++ (moderate)++ (moderate)++ (moderate)++ (moderate)

+++ (strong)+++ (strong)+++ (strong)+++ (strong)

The Urine The Urine Dipstick:Dipstick: BilirrubiBilirrubi

nn

Bilirubin + Diazo salt Bilirubin + Diazo salt --------->---------> Azobilirubin AzobilirubinAcidicAcidic



Bilirubin

Bilirubin is a byproduct of the breakdown of hemoglobin. Normally contains no bilirubin. Presence may be an indication of liver disease, bile duct obstruction or

hepatitis. Since the bilirubin in samples is sensitive to light, exposure of the

urine samples to light for a long period of time may result in a false negative test result.

Ketones

Ketones are excreted when the body metabolizes fats incompletely (ketonuria)


Trace (5 mg/dL)Trace (5 mg/dL)Trace (5 mg/dL)Trace (5 mg/dL)




++++ (160+ mg/dL)++++ (160+ mg/dL)++++ (160+ mg/dL)++++ (160+ mg/dL)

The Urine The Urine Dipstick:Dipstick: KetonesKetones

Acetoacetic Acid + NitroprussideAcetoacetic Acid + Nitroprusside------> ------> Colored ComplexColored Complex



Significance- Diabetic ketoacidosis- Prolonged fasting

Limitations- Interference: expired reagents (degradation with exposure to moisture in air)- Only measures acetoacetate not other ketone bodies (such as in rebound ketosis).

Other Tests- Ketostix (more sensitive tablet version of same assay)- Serum glucose measurement to confirm DKA

Uses and Limitations of Urine Ketone Uses and Limitations of Urine Ketone DetectionDetection

Specific gravity

Depends on the concentration of various solutes in the urine.

Measured by-urinometer

- refractometer

- dipsticks

Specific gravity reflects kidney's ability to concentrate. Want concentrated urine for accurate testing, best is first

morning sample. Low – specimen not concentrated, kidney disease. High – first morning, certain drugs

Urinometer

Take 2/3 of urinometer container with urine Allow the urinometer to float into the urine Read the graduation at the lowest level of

urinary meniscus Correction of temperature & albumin is a must. Urinometer is calibrated at 15or 200cSo for every 3oc increase/decrease add/subtract

0.001For 1gm/dl of albumin add0.001

1.0001.0001.0001.000

1.0051.0051.0051.005

1.0101.0101.0101.010

1.0151.0151.0151.015

1.0201.0201.0201.020

1.0251.0251.0251.025

1.0301.0301.0301.030

XX++ + Polymethyl vinyl ether / maleic anhydride + Polymethyl vinyl ether / maleic anhydride---------------> --------------->

XX++-Polymethyl vinyl ether / maleic anhydride + H-Polymethyl vinyl ether / maleic anhydride + H++

HH++ interacts with a Bromthymol Blue indicator to interacts with a Bromthymol Blue indicator toform a colored complex.form a colored complex.


Read up to 2 minutesRead up to 2 minutesRR: 1.003-1.035RR: 1.003-1.035

The Urine The Urine Dipstick:Dipstick: Specific Specific

GravityGravity

Significance- Diabetes insipidus

Limitations- Interference: alkaline urine

- Does not measure non-ionized solutes (e.g. glucose)

Other Tests- Refractometry

- Hydrometer

- Osmolality measurement (typically used with water deprivation test)

Uses and Limitations of Urine Specific Uses and Limitations of Urine Specific GravityGravity

High specific gravity(hyperosthenuria) Normal-1.016-1.022 Causes

All causes of oliguria

Glycosuria

Low specific gravity(hyposthenuria) All causes of polyuria except glycosuria

Fixed specific gravity (isosthenuria)=1.010

Seen in chronic renal disease when kidney has lost the ability to concentrate or dilute

Blood

Presence of blood may indicate infection, trauma to the urinary tract or bleeding in the kidneys.

False positive readings most often due to contamination with menstrual blood.


TraceTrace (non-hemolyzed) (non-hemolyzed)TraceTrace (non-hemolyzed) (non-hemolyzed)

ModerateModerate (non-hemolyzed) (non-hemolyzed)ModerateModerate (non-hemolyzed) (non-hemolyzed)

TraceTrace (hemolyzed) (hemolyzed)TraceTrace (hemolyzed) (hemolyzed)

+ (weak)+ (weak)+ (weak)+ (weak)

++ (moderate)++ (moderate)++ (moderate)++ (moderate)

+++ (strong)+++ (strong)+++ (strong)+++ (strong)

The Urine The Urine Dipstick:Dipstick: BloodBlood

Diisopropylbenzene dihydroperoxide +Diisopropylbenzene dihydroperoxide +Tetramethylbenzidine Tetramethylbenzidine

------------>------------> Colored Complex Colored ComplexHemeHeme


Lysing agent to lyse red blood cellsLysing agent to lyse red blood cells


Analytic Sensitivity: 10 RBCsAnalytic Sensitivity: 10 RBCs

Significance- Hematuria (nephritis, trauma, etc)- Hemoglobinuria (hemolysis, etc)- Myoglobinuria (rhabdomyolysis, etc)

Limitations- Interference: reducing agents, microbial peroxidases- Cannot distinguish between the above disease processes

Other Tests- Urine microscopic examination- Urine cytology

Uses and Limitations of Urine Blood Uses and Limitations of Urine Blood DetectionDetection

Urinary pH/ reaction

Reaction reflects ability of kidney to maintain normal hydrogen ion concentration in plasma & ECF

Normal= 4.6-8 Tested by- 1.litmus paper

2. pH paper

3. dipsticks

5.05.05.05.0

6.06.06.06.0

6.56.56.56.5

7.07.07.07.0

7.57.57.57.5

8.08.08.08.0

8.58.58.58.5

The Urine The Urine Dipstick:Dipstick: pHpH

HH++ interacts with: interacts with:Methyl Red (at high concentration; low pH) andMethyl Red (at high concentration; low pH) andBromthymol Blue (at low concentration; high Bromthymol Blue (at low concentration; high

pH), to form a colored complexespH), to form a colored complexes(dual indicator system)(dual indicator system)


Read up to 2 minutesRead up to 2 minutesR.R.: 4.5-8.0R.R.: 4.5-8.0

Acidic urine

Ketosis-diabetes, starvation, fever Systemic acidosis UTI- E.coli Acidification therapy

Alkaline urine

Strict vegetarian Systemic alkalosis UTI- Proteus Alkalization therapy

Significance- Acidic (less than 4.5): metabolic acidosis, high-protein diet

- Alkaline (greater than 8.0): renal tubular acidosis (>5.5)

Limitations- Interference: bacterial overgrowth (alkaline or acidic),

“run over effect” effect of protein pad on pH indicator pad

Other Tests- Titrable acidity

- Blood gases to determine acid-base status

Uses and Limitations of Urine pH Uses and Limitations of Urine pH DetectionDetection

GlucoseGlucoseGlucoseGlucose

BilirubinBilirubinBilirubinBilirubin

KetonesKetonesKetonesKetones

Specific GravitySpecific GravitySpecific GravitySpecific Gravity

BloodBloodBloodBlood

pHpHpHpH

ProteinProteinProteinProtein

UrobilinogenUrobilinogenUrobilinogenUrobilinogen

NitriteNitriteNitriteNitrite

Leukocyte EsteraseLeukocyte EsteraseLeukocyte EsteraseLeukocyte Esterase

Buffers from the protein area of Buffers from the protein area of the strip (pH 3.0) spill over to the the strip (pH 3.0) spill over to the pH area of the strip and make the pH area of the strip and make the pH of the sample appear more pH of the sample appear more acidic than it really is.acidic than it really is.

Buffers from the protein area of Buffers from the protein area of the strip (pH 3.0) spill over to the the strip (pH 3.0) spill over to the pH area of the strip and make the pH area of the strip and make the pH of the sample appear more pH of the sample appear more acidic than it really is.acidic than it really is.

pH Run Over EffectpH Run Over Effect

Protein

Presence of protein (proteinuria) is an important indicator of renal disease.

False negatives can occur in alkaline or dilute urine or when primary protein is not albumin.


TraceTraceTraceTrace




++++ (2000 mg/dL)++++ (2000 mg/dL)++++ (2000 mg/dL)++++ (2000 mg/dL)

The Urine The Urine Dipstick:Dipstick: ProteinProtein


HHHH

HH

HH

HHHH

PrPrPrPr

PrPr

PrPr

PrPrPrPr

““Protein Error of Indicators Method”Protein Error of Indicators Method”

PrPr PrPr

PrPr

PrPrPrPr

PrPr

Tetrabromphenol BlueTetrabromphenol Blue(buffered to pH 3.0)(buffered to pH 3.0)

HH++

HH++

HH++HH++

HH++ HH++


Functional Renal- Severe muscular exertion - Glomerulonephritis

- Pregnancy - Nephrotic syndrome

- Orthostatic proteinuria - Renal tumor or infection

Pre-Renal Post-Renal- Fever - Cystitis

- Renal hypoxia - Urethritis or prostatitis

- Hypertension - Contamination with vaginal secretions

Causes of Causes of ProteinuriaProteinuria

Significance- Proteinuria and the nephrotic syndrome.

Limitations- Interference: highly alkaline urine.- Much more sensitive to albumin than other proteins

(e.g., immunoglobulin light chains).

Other Tests- Sulfosalicylic acid (SSA) turbidity test.- Urine protein electrophoresis (UPEP)- Bence Jones protein

Uses and Limitations of Urine Protein Uses and Limitations of Urine Protein DetectionDetection

Urobilinogen

Urobilinogen is a degradation product of bilirubin formed by intestinal bacteria.

It may be increased in hepatic disease or hemolytic disease

0.2 mg/dL0.2 mg/dL0.2 mg/dL0.2 mg/dL

1 mg/dL1 mg/dL1 mg/dL1 mg/dL




The Urine The Urine Dipstick:Dipstick: UrobilinogenUrobilinogen

Urobilinogen + DiethylaminobenzaldehydeUrobilinogen + Diethylaminobenzaldehyde

------->-------> Colored Complex Colored Complex(Ehrlich’s Reagent)(Ehrlich’s Reagent)


Read at 60 secondsRead at 60 secondsRR: 0.02-1.0 mg/dLRR: 0.02-1.0 mg/dL

Significance- High: increased hepatic processing of bilirubin- Low: bile obstruction

Limitations- Interference: prolonged exposure of specimen to oxygen (urobilinogen ---> urobilin)- Cannot detect low levels of urobilinogen

Other Tests- Serum total and direct bilirubin

Uses and Limitations of Urobilinogen Uses and Limitations of Urobilinogen DetectionDetection

Nitrite

Nitrite formed by gram negative bacteria converting urinary nitrate to nitrite


PositivePositivePositivePositive

The Urine The Urine Dipstick:Dipstick: NitriteNitrite

Diazo compound + TetrahydrobenzoquinolinolDiazo compound + Tetrahydrobenzoquinolinol---------->----------> Colored Complex Colored Complex

Nitrite + p-arsenilic acid Nitrite + p-arsenilic acid ------->-------> Diazo compound Diazo compoundAcidicAcidic



Significance- Gram negative bacteriuria

Limitations- Interference: bacterial overgrowth

- Only able to detect bacteria that reduce nitrate to nitrite

Other Tests- Correlate with leukocyte esterase and

- Urine microscopic examination (bacteria)

- Urine culture

Uses and Limitations of Nitrite DetectionUses and Limitations of Nitrite Detection

Leukocytes

Leukocytes (white blood cells) usually indicate infection. Leucocyte esterase activity is due to presence of WBCs in

urine while nitrites strongly suggest bacteriuria.

NegativeNegative

TraceTrace

+ (weak)+ (weak)

++ (moderate)++ (moderate)

+++ (strong)+++ (strong)

The Urine The Urine Dipstick:Dipstick: Leukocyte Leukocyte

EsteraseEsterase

Derivatized pyrrole amino acid ester

------------> 3-hydroxy-5-phenyl pyrroleEsterases

3-hydroxy-5-phenyl pyrrole + diazo salt-------------> Colored Complex

Read at 2 minutesRR: Negative

Analytic Sensitivity: 3-5 WBCs

Chemical Principle

Significance- Pyuria- Acute inflammation- Renal calculus

Limitations- Interference: oxidizing agents, menstrual contamination

Other Tests- Urine microscopic examination (WBCs and bacteria)- Urine culture

Uses and Limitations of Leukocyte Esterase Uses and Limitations of Leukocyte Esterase DetectionDetection

Normal Values

Negative results for glucose, ketones, bilirubin, nitrites, leukocyte esterase and blood.

Protein negative or trace. pH 5.5-8.0 Urobilinogen 0.2-1.0 Ehrlich units

Microscopic examination

Microscopic urinalysis is done simply pouring the urine sample into a test tube and centrifuging it (spinning it down in a machine) for a few minutes. The top liquid part (the supernatant) is discarded. The solid part left in the bottom of the test tube (the urine sediment) is mixed with the remaining drop of urine in the test tube and one drop is analyzed under a microscope

Per High Power Field (HPF) (400x)Per High Power Field (HPF) (400x)– > 3 erythrocytes> 3 erythrocytes– > 5 leukocytes> 5 leukocytes– > 2 renal tubular cells> 2 renal tubular cells– > 10 bacteria> 10 bacteria

Per Low Power Field (LPF) (200x)Per Low Power Field (LPF) (200x)– > 3 hyaline casts or > 1 granular cast> 3 hyaline casts or > 1 granular cast– > 10 squamous cells (indicative of contaminated specimen)> 10 squamous cells (indicative of contaminated specimen)– Any other cast (RBCs, WBCs)Any other cast (RBCs, WBCs)

Presence of:Presence of:– Fungal hyphae or yeast, parasite, viral inclusionsFungal hyphae or yeast, parasite, viral inclusions– Pathological crystals (cystine, leucine, tyrosine)Pathological crystals (cystine, leucine, tyrosine)– Large number of uric acid or calcium oxalate crystalsLarge number of uric acid or calcium oxalate crystals

Microscopic ExaminationMicroscopic ExaminationAbnormal Abnormal FindingsFindings

Erythrocytes- “Dysmorphic” vs. “normal” (> 10 per HPF)

Leukocytes- Neutrophils (glitter cells) More than 1 per 3 HPF- Eosinophils Hansel test (special stain)

Epithelial Cells- Squamous cells Indicate level of contamination- Renal tubular epithelial cells Few are normal- Transitional epithelial cells Few are normal

- Oval fat bodies Abnormal, indicate Nephrosis

Microscopic Microscopic ExaminationExamination CellsCells

Microscopic Microscopic ExaminationExamination RBCsRBCs

Microscopic Microscopic ExaminationExamination RBCsRBCs

Microscopic Microscopic ExaminationExamination WBCsWBCs

Microscopic Microscopic ExaminationExamination Squamous CellsSquamous Cells

Microscopic Microscopic ExaminationExamination Tubular Epithelial Tubular Epithelial

CellsCells

Microscopic Microscopic ExaminationExamination Transitional CellsTransitional Cells

Microscopic Microscopic ExaminationExamination Transitional CellsTransitional Cells

Microscopic Microscopic ExaminationExamination Oval Fat BodyOval Fat Body

Microscopic Microscopic ExaminationExamination LE CellLE Cell

Bacteria- Bacteriuria More than 10 per HPF

Yeasts- Candidiasis Most likely a contaminant

but should correlate withclinical picture.

Viruses- CMV inclusions Probable viral cystitis.

Microscopic Microscopic ExaminationExamination Bacteria & YeastsBacteria & Yeasts

Microscopic Microscopic ExaminationExamination BacteriaBacteria

Microscopic Microscopic ExaminationExamination YeastsYeasts

Microscopic Microscopic ExaminationExamination YeastsYeasts

Microscopic Microscopic ExaminationExamination

CytomegalovirusCytomegalovirus

casts

Urinary casts are cylindrical aggregations of particles that form in the distal nephron, dislodge, and pass into the urine. In urinalysis they indicate kidney disease. They form via precipitation of Tamm-Horsfall mucoprotein which is secreted by renal tubule cells.

Microscopic Microscopic ExaminationExamination CastsCasts

Types of casts

Acellular casts

Hyaline casts

Granular casts

Waxy casts

Fatty casts

Pigment casts

Crystal casts

Cellular casts

Red cell casts

White cell casts

Epithelial cell cast

Erythrocyte Casts: Glomerular diseases

Leukocyte Casts: Pyuria, glomerular disease

Degenerating Casts:- Granular casts Nonspecific (Tamm-Horsfall protein)- Hyaline casts Nonspecific (Tamm-Horsfall protein)- Waxy casts Nonspecific- Fatty casts Nephrotic syndrome (oval fat body casts)

Microscopic Microscopic ExaminationExamination CastsCasts

Red cell casts

The presence of red blood cells within the cast is always pathologic, and is strongly indicative of glomerular damage.

They are usually associated with nephritic syndromes.

Microscopic Microscopic ExaminationExamination RBCs Cast - RBCs Cast -

HistologyHistology

Microscopic Microscopic ExaminationExamination RBCs CastRBCs Cast

Microscopic Microscopic ExaminationExamination RBCs Cast - RBCs Cast -

HistologyHistology

White blood cell casts

Indicative of inflammation or infection, pyelonephritis acute allergic interstitial nephritis, nephrotic syndrome, or post-streptococcal acute glomerulonephritis

Microscopic Microscopic ExaminationExamination WBCs CastWBCs Cast

Epithelial casts

This cast is formed by inclusion or adhesion of desquamated epithelial cells of the tubule lining.

These can be seen in acute tubular necrosis and toxic ingestion, such as from mercury,

diethylene glycol, or salicylate.

Microscopic Microscopic ExaminationExamination Tubular Epith. CastTubular Epith. Cast

Microscopic Microscopic ExaminationExamination Tubular Epith. CastTubular Epith. Cast

Granular casts

Granular casts can result either from the breakdown of cellular casts or the inclusion of aggregates of plasma proteins (e.g., albumin) or immunoglobulin light chains

indicative of chronic renal disease

Microscopic Microscopic ExaminationExamination Granular CastGranular Cast

Hyaline casts

The most common type of cast, hyaline casts are solidified Tamm-Horsfall mucoprotein secreted from the tubular epithelial cells

Seen in fever, strenuous exercise, damage to the glomerular capillary

Microscopic Microscopic ExaminationExamination Hyaline CastHyaline Cast

Waxy casts

waxy casts suggest severe, longstanding kidney disease such as renal failure(end stage renal disease).

Waxy casts

Microscopic Microscopic ExaminationExamination Waxy CastWaxy Cast

Fatty casts

Formed by the breakdown of lipid-rich epithelial cells, these are hyaline casts with fat globule inclusions

They can be present in various disorders, including

nephrotic syndrome, diabetic or lupus nephropathy, Acute tubular necrosis

Fatty casts

Microscopic Microscopic ExaminationExamination Fatty CastFatty Cast

Crystal casts

Though crystallized urinary solutes, such as oxalates, urates, or sulfonamides, may become enmeshed within a hyaline cast during its formation.

The clinical significance of this occurrence is not felt to be great.

Contents of normal urine m/s

Contains few epithelial cells, occasional RBC’s, few crystals.

Crystals in urine

Crystals in acidic urine Uric acid Calcium oxalate Amorphous urate Cystine Leucine

Crystals in alkaline urine Ammonium Magnesium phosphates

(Triple phosphate crystals) Amorphous phosphate Calcium carbonate

Microscopic Microscopic ExaminationExamination Uric acid crystals Uric acid crystals

Microscopic Microscopic ExaminationExaminationCalcium Oxalate CrystalsCalcium Oxalate Crystals

Microscopic Microscopic ExaminationExaminationCalcium Oxalate CrystalsCalcium Oxalate Crystals

Dumbbell Dumbbell Shape Shape

Microscopic Microscopic ExaminationExamination Amorphous Urates Amorphous Urates

CrystalsCrystals

Microscopic Microscopic ExaminationExaminationTriple Phosphate CrystalsTriple Phosphate Crystals

Microscopic Microscopic ExaminationExaminationAmorphous phosphate Amorphous phosphate

CrystalsCrystals

Microscopic Microscopic ExaminationExamination Cystine CrystalsCystine Crystals

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Examination of Urine