Urinalysis

Urinalysis
Microscopic examination
Komson Wannasai, M.D.,FRCPath.
Department of Pathology
Faculty of Medicine
Chiang Mai University
Specimen
Collection
– First morning voiding
– Most concentrated
– Record collection time
– Type of specimen
– Clean catch
– Analyzed within 2 hours of collection
– Refrigerator 4oC
– Free of debris or vaginal secretions
Clean Catch
Specimen Collection
Supra-pubic Needle Aspiration
Types of Analysis
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Macroscopic Examination
Chemical Analysis (Urine Dipstick)
Microscopic Examination
Culture (not covered in this lecture)
Cytological Examination
Macroscopic Examination
Odor:
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Ammonia-like:
Foul, offensive:
inflammation
Sweet:
Fruity:
Maple syrup-like:
(Urea-splitting bacteria)
Old specimen, pus or
Glucose
Ketones
Maple Syrup Urine Disease
Color:
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Colorless
Deep Yellow
Yellow-Green
Red
Brownish-red
Brownish-black
Diluted urine
Concentrated Urine, Riboflavin
Bilirubin / Biliverdin
Blood / Hemoglobin
Acidified Blood (Actute GN)
Homogentisic acid (Melanin)
Macroscopic Examination
Turbidity:
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Typically cells or crystals.
Cellular elements and bacteria will clear by
centrifugation.
Crystals dissolved by a variety of methods
(acid or base).
Microscopic examination will determine
which is present.
Chemical Analysis
Chemical Analysis
Urine Dipstick
Glucose
Bilirubin
Ketones
Specific Gravity
Blood
pH
Protein
Urobilinogen
Nitrite
Leukocyte Esterase
Microscopic Examination
General Aspects
Preservation
- Cells and casts begin to disintegrate in 1 - 3 hrs. at
room temp.
- Refrigeration for up to 48 hours (little loss of cells).
Specimen concentration
- Ten to twenty-fold concentration by centrifugation.
Types of microscopy
- Phase contrast microscopy
- Polarized microscopy
- Bright field microscopy with special staining
(e.g., Sternheimer-Malbin stain)
Microscopic Examination
Abnormal Findings
Per High Power Field (HPF) (400x)
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>
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>
3 erythrocytes
5 leukocytes
2 renal tubular cells
10 bacteria
Per Low Power Field (LPF) (200x)
– > 3 hyaline casts or > 1 granular cast
– > 10 squamous cells (indicative of contaminated specimen)
– Any other cast (RBCs, WBCs)
Presence of:
– Fungal hyphae or yeast, parasite, viral inclusions
– Pathological crystals (cystine, leucine, tyrosine)
– Large number of uric acid or calcium oxalate crystals
Microscopic Examination
Cells
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
- Renal tubular epithelial cells
- Transitional epithelial cells
- Oval fat bodies
Indicate level of
contamination
Few are normal
Few are normal
Abnormal, indicate Nephrosis
Methodology
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Well-mixed urine (usually 10-15 ml) is
centrifuged in a test tube.
– About 2-3,000 rpm) for 5 minutes
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Supernate is decanted and a volume
of 0.2 to 0.5 ml is left inside the tube.
Flicking the bottom of the tube several
times.
A drop of resuspended sediment is
poured onto a glass slide and
coverslipped.
Examination
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Low power to identify most crystals, casts,
squamous cells, and other large objects
The numbers of casts seen are usually
reported as number of each type found per
low power field (LPF).
– Example: 5-10 hyaline casts/L casts/LPF.

Next, examination is carried out at high
power to identify crystals, cells, and bacteria.
– The various types of cells are usually described as
the number of each type found per average high
power field (HPF).
– Example: 1-5 WBC/HPF
Microscopic Examination
RBCs
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Red blood cells in
urine appear as
refractile disks.
With
hypertonicity of
the urine, the
RBC's begin to
have a crenated
appearance.
Microscopic Examination
RBCs
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Irregular outlines of
many of these
RBC's, compared to
two relatively
normal RBC's at the
center left of the
right panel.
These abnormal
RBC's are
dysmorphic
RBC's.
Microscopic Examination
WBCs
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These white blood
cells in urine have
lobed nuclei and
refractile
cytoplasmic
granules.
If two or more
leukocytes per each
high power field
appear in noncontaminated urine,
the specimen is
probably abnormal.
Microscopic Examination
Squamous Cells
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Large polygonal
squamous epithelial
cells with small
nuclei are seen
here.
Their significance is
that they represent
possible
contamination of
the specimen with
skin flora.
Microscopic Examination
Tubular Epithelial Cells
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Usually larger than
granulocytes
Contain a large
round or oval
nucleus
Normally slough into
the urine in small
numbers
In nephrotic
syndrome and in
conditions leading to
tubular degeneration,
the number sloughed
is increased.
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When lipiduria
occurs, these cells
contain endogenous
fats.
When filled with
numerous fat
droplets, such cells
are called oval fat
bodies.
Oval fat bodies
exhibit a "Maltese
cross" configuration
by polarized light
microscopy.
Microscopic Examination
Tubular Epithelial Cells
Microscopic Examination
Oval Fat Body
Microscopic Examination
Transitional Cells
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Renal pelvis,
ureter, or
bladder
More regular cell
borders, larger
nuclei, and
smaller overall
size than
squamous
epithelium
Microscopic Examination
Transitional Cells
Microscopic Examination
Bacteria & Yeasts
Bacteria
- Bacteriuria
Yeasts
- Candidiasis
contaminant
with
Viruses
- CMV inclusions
More than 10 per HPF
Most likely a
but should correlate
clinical picture.
Probable viral cystitis.
Microscopic Examination
Bacteria
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Common in urine specimens
Abundant normal microbial flora
of the vagina or external urethral
meatus
Rapidly multiply in urine standing
at room temperature
Should be interpreted in view of
clinical symptoms.
Microscopic Examination
Bacteria
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Diagnosis of bacteriuria in a case of
suspected urinary tract infection requires
culture
More than 100,000/ml of one organism
reflects significant bacteriuria
Multiple organisms reflect contamination.
However, the presence of any organism
in catheterized or suprapubic tap
specimens should be considered
significant.
Microscopic Examination
Bacteria
Microscopic Examination
Yeasts
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Yeast cells may be
contaminants or
represent a true yeast
infection.
Difficult to distinguish
from red cells and
amorphous crystals
but are distinguished
by their tendency to
bud.
Most often they are
Candida, which may
colonize bladder,
urethra, or vagina.
Microscopic Examination
Yeasts
Microscopic Examination
Casts
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Urinary casts are formed only in
the distal convoluted tubule
(DCT) or the collecting duct
(distal nephron).
The proximal convoluted tubule
(PCT) and loop of Henle are not
locations for cast formation.
Microscopic Examination
Casts
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Hyaline casts are
composed primarily of a
mucoprotein (TammHorsfall protein)
secreted by tubule cells.
The Tamm-Horsfall
protein secretion (green
dots) is illustrated in
the diagram, forming a
hyaline cast in the
collecting duct.
Microscopic Examination
Casts
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An example of
glomerular
inflammation with
leakage of RBC's to
produce a red blood
cell cast is shown in
the diagram:
Microscopic Examination
RBCs Cast
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The presence of
this red blood
cell cast in on
urine microscopic
analysis suggests
a glomerular or
renal tubular
injury.
Microscopic Examination
RBCs Cast - histology
Microscopic Examination
WBCs Cast
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This white
blood cell cast
suggests an
acute
pyelonephritis.
Microscopic Examination
Tubular Epith. Cast
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This renal
tubular cell
cast suggests
injury to the
tubular
epithelium.
Microscopic Examination
Granular Cast
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These are
granular casts,
with a roughly
rectangular
shape.
Microscopic Examination
Hyaline Cast
Microscopic Examination
Waxy Cast
Microscopic Examination
Fatty Cast
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Severe renal
dysfunction
Oval fat bodies
Renal tubular epth.
cells or
macrophages with
ingested lipid(fat)
DM with renal
degenaration toxic
nephrosis
Microscopic Examination
Broad cast
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GRAVE
PROGNOSIS
Urinary stasis
Chronic renal
disease
Proteinuria
Microscopic
Examination
Casts
Erythrocyte Casts:
Glomerular diseases
Leukocyte Casts:
Pyuria, glomerular disease
Degenerating Casts:
- Granular casts
- Hyaline casts
- Waxy casts
- Fatty casts
(oval fat body casts)
Nonspecific (Tamm-Horsfall
protein)
Nonspecific (Tamm-Horsfall
protein)
Nonspecific
Nephrotic syndrome
Significance of Cellular Casts
Erythrocyte Casts
Leukocyte Casts
Bacterial Casts
Single Erythrocytes
Single Leukocytes
Single Bacteria
Verrier-Jones & Asscher, 1991.
Microscopic
Examination
- Urate
Ammonium biurate
Uric acid
- Triple Phosphate
- Calcium Oxalate
- Amino Acids
Cystine
Leucine
Tyrosine
- Sulfonamide
Crystals
Microscopic Examination
Calcium Oxalate Crystals
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These are
oxalate crystals,
which look like
little envelopes
(or tetrahedrons,
depending upon
your point of
view).
Oxalate crystals
are common.
Microscopic Examination
Triple Phosphate Crystals
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These "triple
phosphate"
crystals look like
rectangles, or
coffin lids if you
are feeling
depressed.
Microscopic Examination
Triple Phosphate Crystals
Microscopic Examination
Cystine Crystals
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These cystine
crystals are
shaped like stop
signs.
Cystine crystals
are quite rare.
Microscopic Examination
Cystine Crystals
Microscopic Examination
Urate Crystals
Microscopic Examination
Leucine Crystals
Microscopic Examination
Ammonium Biurate Crystals
Microscopic Examination
Cholesterol Crystals
Uric acid
Amorphous urate
Calcium oxalate
Amorphous
phosphate
Triple
phousphate
Ammonium
biurate
Miscellaneous
การรายงานผล

เซลล์ต่าง ๆ เช่น เม็ดเลือดแดง, เม็ดเลือดขาว,
epithelial cells, และ oval fat body ให้นับด้วย
กําลังขยายสูง (objective 40x) ดูประมาณ 10-15
fields แล้วมาเฉลี่ยต่อ 1 field รายงานผลเป็ น 01, 1-2, 2-3, 3-5, 5-10, 10-25, 25-50, 50-100, 100200, หรือ >200 ต่อ high power (HP) หรือ high
dry (HD) หรือ high power field (hpf) หรือมากจน
นับไม่ได้ให้รายงานเป็ น numerous
การรายงานผล
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ถ้าเซลล์ชนิดใดชนิดหนึ่ งมีมากจนบังไม่ให้เห็น
เซลล์อีก 2 ชนิดชัด ให้รายงานเซลล์ อีก 2 ชนิดที่
น้ อยกว่าเป็ น few, moderate หรือ many
Cast ชนิดต่าง ๆ ให้นับด้วย low power, (LP) หรือ
Low dry (LD) หรือ Low power field (lpf) และ
รายงานเหมือนข้อ 1 การศึกษารายละเอียดใช้
high power
การรายงานผล

Bacteria, crytal ให้บอกชนิด รายงาน
เป็ น few, moderate, numerous หรือ 1+
ถึง 4+ จากการดูด้วย HP ถ้าพบ
Trichomonas, oil droplets, sperm,
yeast ให้รายงานเป็ น few, moderate
หรือ numerous จากการดูด้วย HP