THENUMBEROF FORMEDELEMENTSIN THE URINARYSEDIMENTOFPATIENTS SUFFERINGFROMHEARTDIS-EASE, WITH PARTICULAR REFERENCETO THE STATEOF HEARTFAILURE

By HAROLDJ. STEWARTAND NORMANS. MOORE

(From the Hospital of the Rockefeler Institute for Medical Research, New York)

(Received for publication July 7, 1930)

It is well known that casts, red blood cells and white blood cells maybe present in the urinary sediment of patients suffering from heartfailure. In the manner that specimens of urine are usually obtainedit is not possible to gain an accurate notion of the numbers of cellswhich are present, since variations in salt concentration and reactionof the urine may result in partial or complete disappearance of theformed elements of the urine. Addis (1) recommended a procedurewhich has for its object the secretion by the kidneys of urine of suchhigh specific gravity and acidity that the integrity of the formedelements of the urine is maintained. By this means the number ofelements in urinary sediment formed in a 12-hour period may beestimated. Addis (2) found that the number of casts passed in a12-hour period varied in normal individuals between 0 and 4,270, theaverage being 1,040; the number of red blood cells between 0 and425,000, the average being 65,700; the number of white blood andepithelial cells between 32,400 and 1,835,000, the average being322,500. The casts were hyallne; granular casts were not observed.

The present study is concerned with the estimation of the number offormed elements in the urines of patients suffering from chronic heartdisease, especially of the so-called arteriosclerotic type, more particu-larly with reference to the state of heart failure of the congestive type.

The patients were at rest in bed and were in water equilibrium.Observations were made in patients suffering from the congestivetype of heart failure, and again in the same patients after the signsand symptoms of heart failure had disappeared. In others, observa-

409

URINARY SEDIMENT IN HEART FAILURE

tions could be made only during the stage of decompensation, while inothers still, only after the return to the state of compensation. Inaddition there are data in a few patients who had never suffered fromheart failure. Most of the patients were males; catheterization offemales is necessary if accurate counts of the cells are desired. Thesediment was studied according to the technique described by Addis(1). The procedure begins after breakfast. The patient is given nofluid following this meal until after the end of the test the next morning(6 a.m.). The patient voids at 6 p.m.; this specimen is discarded.The total night urine (6 p.m.-6 a.m.) is obtained at one voiding 12hours later. The casts, red blood and white blood cells are counted insamples of this specimen.

OBSERVATIONS

The number of formed elements in the urine in the presence of heartfailure of the congestive type. In 18 patients (tables 1 and 2), thenumber of casts in 12-hour samples varied between 0 and 463,740,the average number being 66,485 (table 3). In 6 instances the numberwas within the normal range (4 none, 2 high) and in the 12 remaining,greater than the highest normal value observed by Addis (2). Granu-lar casts were found in approximately half the urines. The red bloodcell counts ranged from 72,210 to 3,090,000, the average being 834,754.In 9 patients the number was normal (1 average, 8 high) and in the 9remaining greater than the highest normal value. The white bloodand epithelial cells varied between 70,000 and 17,877,000, the averagebeing 3,089,302. In 13 patients the range was normal (1 average, 12high), and in the 5 remaining greater than the highest normal value.

In the presence of heart failure of the congestive type, therefore,the number of casts was definitely increased in approximately two-thirds of the cases studied, the red blood cells increased in approxi-mately one-half, and the white blood cells in approximately one-third.The average number of casts was 60 times and the average number ofred blood cells and of white blood cells 10 to 15 times greater than innormal subjects.

The number of formed elements in the urine following recovery fromcardiac decompensation. After recovery from heart failure in 16patients the number of casts varied between 0 and 141,000 (tables 1

410

HAROLDJ. STEWARTAND NORMANS. MOORE

and 4), the average being 34,600 (table 3). In 4 instances the numberwas normal (4 none) and in 12, greater than normal. Granular castswere found in approximately 25 per cent. Red blood cells variedbetween 165,000 and 3,090,000, the average being 917,515. In 4patients the number was normal (4 high) and in 12, greater than thehighest normal value. The white blood and epithelial cells rangedbetween 304,000 and 2,520,000, the average being 1,151,187. In 13patients the range was within normal limits (2 average, 11 high) andin 3, greater than the highest normal value.

In our experience, it appears therefore to be a fact that approxi-mately 75 per cent of the patients who had recently recovered fromheart failure of the congestive type passed in their urines a greaternumber of casts than normal individuals, an increased number of redblood cells, but in the case of white blood cells a number greater in one-fourth of the patients than the highest number in normal individuals.

Comparison of the numbers of formed elements present in the urineduring heart failure and following recovery. When observations (11patients) were possible during the stage of heart failure as well as afterreturn to compensation (table 1), we found no fixed tendency of direc-tion; that is to say, the casts, red blood cells and white blood cells wereas frequently increased following the disappearance of signs of heartfailure as they were decreased (see discussion). On comparison of theaverage numbers (table 3), however, it appears that casts and whiteblood cells were passed in approximately twice the quantity duringdecompensation as after recovery, but the red blood cells in approxi-mately the same numbers.

The number of formed elements in the urine of patients who have notsuffered from heart failure of the congestive type. In 7 cardiac patientswho had not suffered from heart failure (table 5) the number of castsranged from 0 to 80,000, the average being 17,792 (table 3). In 4individuals, the range was normal (2 none, 2 high) and in 3, greaterthan the highest normal value. In approximately half the patientsgranular casts were found (table 5). The red blood cells varied be-tween 22,250 and 428,000, the average being 162,531. In all instancesthe count was within the normal range. The white blood cells variedbetween 96,000 and 1,788,000, the average being 809,555. In eachcase the range was normal.

411

TAB]Comparison of Ihe ntmber of formed dements found in I

I

40M.

State with reference to heart failure

During failure (++++)tRecovered

47 During failure (+++)M. Recovered

74 During failure (+)M. Recovered

68 During failure (++)M. Recovered

60 During failure (+)M. Recovered

40F.

During failure (++++)During failure (+ ++)During failure (++)Recovered

58 During failure (++)M. Recovered

34 During failure (++++)M. Recovered

34 During failure (+)M. Recovered

27 During failure (++)M. Recovered

40 During failure (++++)M. Recovered

Diagnosis

Etiological

Arteriosclerosis

Arteriosclerosis

Arteriosclerosis

Arteriosclerosis

Arteriosclerosis

Hypertension,180/130

Arteriosclerosis,hypertension

Rheumatic fever

Rheumatic fever

Rheumatic fever

Rheumatic fever

Anatomical

Cardiac hypertrophy, mitralinsufficiency, chronic myo-carditis

Cardiac hypertrophy, mitralinsufficiency, chronic myo-carditis

Cardiac hypertrophy

Ph'

Auricl;tion

Auricttion

Aurication

Cardiac hypertrophy, chronic Normmyocarditis, VPL§ C.F

Chronic myocarditis

Cardiac hypertrophy, mitralinsufficiency, aortic rough-ening,VPL

Cardiac hypertrophy, mitralinsufficiency, chronic myo-carditis

Cardiac hypertrophy, mitralstenosis, mitral insuffi-ciency, aortic roughening

Cardiac hypertro phy, mitral Auricstenosis tio

Cardiac hypertrophy, mitralinsufficiency and stenosis,aortic roughening

Cardiac hypertrophy, mitralinsufficiency and stenosis

NormC.1

NormtraiI-E

Aurictioi

Aurictio:

Auri(tio

Aurittio

* The diagnoses in this table as well as in tables 2, 4 and 5 conform to the nomenclature for cardiac dialt The degree of heart failure is indicated by + signs in this table as well as in tables 2 and 4.t In this table as well as in tabled 2 and 4, + and 0 indicate thepresence or absence of the sign.I VPL = left ventricularpreponderancein this table as well as i tables 2, 4and S.

C.H.F. - heart failure of the congestive type in this table as well as in tables 2, 4and S.I-HB - incomplete heart block in this table as well as in tables 2, 4 and 5.

412

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In such patients the number of casts was therefore increased, theaverage being 20 times that in normal subjects; the increase was not sogreat, however, as in cases of heart failure of the congestive type.The red cell and white cell counts were, however, definitely less; theaverage numbers though twice as great as in normal individuals were,nevertheless, within normal limits.

Urinary sediment and renalfunction. Renal function was studied incertain patients by means of the urea clearance test (3) and the excre-tion of phenolsulphonphthalein, but no relationship was observedbetween the degree of renal impairment and the number of casts, andred and white blood cells passed in 12 hours (tables 1, 2, 4 and 5).

DISCUSSION

In cardiac patients who exhibited no signs of heart failure Stewartand McIntosh (4) found that renal function measured by the VanSlyke index of urea excretion (5) and phenolsulphonphthalein excre-tion was usually normal, without reference to whether they had pre-viously suffered attacks of congestive heart failure. Although normalin these respects, diminution of function was detected, nevertheless, inthese individuals by means of the concentration and dilution tests (4);their kidneys could not in many instances excrete urine of high orof low specific gravity. This impairment was most frequent afterattacks of heart failure of the congestive type. It is of course wellknown that decrease in renal function as measured by the urea indexand phenolsulphonphthalein excretion is frequently observed duringheart failure of the congestive variety and that return toward normaltakes place as the signs of failure disappear (6). This is commonlyattributed to congestion of the kidneys. No studies have yet beenpublished of the number of formed elements in the urine of suchpatients. Increase in albumin in the urine and presence of casts, redblood cells and white blood cells in heart failure are, as abnormality inthe case of chemical tests, commonly attributed to congestion. Theactual numbers we have now counted. The cases studied are too fewfor statistical treatment, but the degrees of heart failure encounteredwere sufficient, we think, to suggest the limnits within which thenumbers may be expected to fall.The most consistent finding was increase in the number of casts, the

418

HAROLDJ. STEWARTAND NORMANS. MOORE

average being 20 to 60 times greater than normal, depending on theseverity of the disease. The number was smallest when failure of thecongestive type had not occurred, somewhat greater when it had,though at the moment no signs were present, and greater stil whenthey were. Granular casts which Addis (2) did not find in the urinesof normal individuals were found in approximately half the cases.

During heart failure and after recovery increased numbers of redand white blood cells occur but almost as frequently they are withinthe normal range. When heart failure has not taken place red andwhite blood cells are within normal range, although the averages areapproximately twice those of normal individuals. But in patients whohave experienced heart failure the numbers are 10 to 15 times greaterthan normal. In Addis's (2) opinion it is only the appearance of a

TABLE 6

Comparison of average numbers of casts, red blood cells and white blood ceUs found in theurine in different states of heart disease

Casts.... No attacks of heart failure < Recovered from failure < During failure

Red bloodcells....... No attacks of heart failure < Recovered from failure = During failure

White bloodcells. No attacks of heart failure < Recovered from failure <During failure

million or more red cells that can be regarded as significant. Wecouldfind no association, however, between the number of formed elementsand the number of attacks of heart failure, nor between the degree ofimpairment of renal function (the urea clearance test and the phenol-sulphonphthalein excretion) and the number of formed elements inthe urine. Etiology, so far as we could see, played no r6le, though theseries is small to adopt an opinion on this point. Renal failure casts(Addis (7)) were not observed. On the whole it is surprising that thenlumber of casts, red blood cells and white blood cells in the urines ofcardiac patients is so small and that it is so little increased duringcardiac decompensation (table 6), that there is, in short, so littlealteration in function.

Wewish to emphasize a point already made by Addis (2), namely

419

URINARY SEDIMENT IN HEART FAILURE

that the numbers of casts, red blood cells and white blood cells haveno individual significance. In these cases furthermore the numbers offormed elements counted were small; they serve only to define theorder of magnitude and, to establish the limits or range of variation.It is only when they are large, as in Bright's disease, that the absolutenumbers are significant. It is of course for this reason that the com-parison between the stages of absence and presence of heart failure inthe same patient sometimes shows decrease and sometimes increase;in this sense alone greater numbers of casts and white blood cells arefound in the presence of heart failure, though the number of red bloodcells is approximately the same.

SUMMARY

1. The number of casts found in 12 hours is usually increased inpatients suffering from cardiac disease, although the number may benormal. If the average numbers are considered, the greatest numberswere passed by those patients suffering from heart failure of the con-gestive type; the numbers were fewer after recovery and fewer still inthose who had never suffered from this illness. Granular casts werefrequently found.

2. The number of red blood cells in the urine of patients who hadexperienced cardiac decompensation was frequently greater than thehighest normal value, but within the limits in those who had neversuffered from heart failure. The average number of red blood cellsfound in those cases which had never experienced heart failure wastwice as great as that in normal individuals; in those who were suffer-ing from heart failure or had recovered from it, however, the averagenumber was 10 to 15 times as great as in normal individuals.

3. The number of white blood ceUs was normal in the urine of thosepatients who had not suffered from heart failure, but the averagenumber was approximately twice the average observed in normalindividuals. The number was usually within the normal range bothduring and after recovery from cardiac decompensation; the averagenumber, however, was greater approximately 9 and 3 times respec-tively than that in normal individuals, the average being less inpatients without heart failure than in those who had recently recoveredfrom it and less than in those who were still suffering.

420

HAROLDJ. STEWARTAND NORMANS. MOORE 421

BIBLIOGRAPHY

1. Addis, T., J. Am. Med. Assoc., 1925, lxxxv, 163. A Clinical Classification ofBright's Diseases.

2. Addis, T., J. Clin. Invest., 1926, ii, 409. The Number of Formed Elements inthe Urinary Sediment of Normal Individuals.

3. Moller, E., McIntosh, J. F., and Van Slyke, D. D., J. Clin. Invest., 1928, vi,427. Studies of Urea Excretion. II. Relationship Between Urine Volumeand the Rate of Urea Excretion by Normal Adults.

4. Stewart, H. J., and McIntosh, J. F., J. Clin. Invest., 1928, vi, 325. The Func-tion of the Kidneys in Patients Suffering from Chronic Cardiac Disease with-out Signs of Heart Failure.

5. Van Slyke, D. D., Linder, G. C., Huller, A., Leiter, L., and McIntosh, J. F.,J. Clin. Invest., 1926, ii, 255. The Excretion of Ammonia and TitratableAcid in Nephritis.

6. McLean, F. C., J. Exp. Med., 1915, xxii, 366. The Numerical Laws Governingthe Rate of Excretion of Urea and Chlorides in Man. II. The Influence ofPathological Conditions and of Drugs on Excretion.

7. Addis, T., J. Am. Med. Assoc., 1925, lxxxiv, 1013. Renal Failure Casts.