MICROSCOPIC EXAMINATION of URINE

(Part 2)
HYALINE CASTS

Point of Description
URINE CASTS
reference
 Unique to kidney
 Formed within the lumen of DCT & CD Appearance • Colorless homogenous
 Provides microscopic view of condition w/in matrix
nephron
 Lpf  detection/Scanning around cover slip Sources of • Mucus, fibers, hair,
edge Identification increased lighting
 Low refractive index  observe in subdued error
light
 Reporting: Ave. #/ lpf Reporting • Average number per lpf

- Can’t be seen on blood and other fluids, only in Complete • Protein

the urine urinalysis
• Blood (exercise)
- Reporting: Quantitative correlation
- Need to count because the number of cast is • Color (exercise)
significant
- Cast matrix dissolves quickly in dilute, alkaline Clinical • Glomerulonephritis
urine significance
• Pyelonephritis
• Chronic renal disease
Casts (Composition and Formation)
• Congestive heart failure
 Tamm-Horsfall protein (THP)
• Stress and exercise 0-2/lpf
 Also known as Uromodulin (UMOD)
 Major constituent of cast
 Stress & exercise  It is the most frequently seen cast, which
 It is a glycoprotein excreted by the consists almost entirely of Tamm-Horsfall
RTE cells of the DCT and in the upper protein/ uromodulin.
CD  Sternheimer-Malban stain produces pink color
 Excreted at relatively constant rate in hyaline casts.
under normal conditions  Increased visualization can be obtained by
 The rate of excretion appears to Phase microscopy
increase under conditions of stress  consisting of normal parallel sides and rounded
and strenuous exercise ends, cylindroid forms, and wrinkled or
 Albumin, immunoglobulin - incorporated convoluted shapes that indicate aging of the
into the cast matrix cast matrix
 Protein gel  urine-flow stasis, acidity,
NOTE:
Na+, Ca++
 Tapered end  formed at the junction of - Beginning of all casts
ALH & DCT - “Ice plastic bag” – very translucent without other
contents
-Cylindroids
- 0-2 hyaline casts is still considered normal
 Cylindruria  presence of urinary cast
RBC CASTS WBC Casts

Point of Description Point of Description

reference reference

Appearance • Orange-red color, cast Appearance • Cast matrix containing

matrix containing RBCs WBCs

Sources of • WBC clumps

Sources of • RBC clumps Identification
Identification error
error
Reporting • Average number per lpf
Reporting • Average number per lpf

Complete • RBCs Complete • WBCs Protein LE

urinalysis urinalysis (Leukocyte Esterase)
correlation • Blood
correlation
• Protein
Clinical • Pyelonephritis
Clinical • Glomerulonephritis significance
• Acute interstitial
significance
• Strenuous exercise 0-2/lpf nephritis

- WBC casts matrix are cylindroid in shape, WBC

- “Ice plastic bag with RBC inside” clumps are irregular in shape and circular
- 0-2 lpf

 Finding of RBCs in the urine indicates bleeding  They are most frequently associated with
from an area within the genitourinary tract pyelonephritis and are a primary marker for
 RBC casts associated with glomerular damage distinguishing pyelonephritis (upper UTI) from
usually associated with proteinuria and (Cystitis) lower UTIs.
dysmorphic erythrocytes  Supravital staining may be necessary to
 In the presence of massive hemoglobinuria or demonstrate the characteristic nuclei
myoglobinuria, homogenous orange-red or red-  It is particularly helpful for differentiating WBC
brown casts may be observed. casts from RTE casts.
 They are associated with the acute tubular
necrosis often caused by the toxic effects of
massive hemoglobinuria that can lead to renal
failure.
Bacterial Casts Epithelial Cell Casts (Renal Tubular)

Point of Description Point of Description

reference reference

Appearance • Bacilli bound to protein Appearance • RTE cells attached to

matrix protein matrix

Sources of • Granular casts Sources of • WBC cast

Identification Identification
error error

Reporting • Average number per lpf Reporting • Average number per lpf

Complete • Protein RTE cells

Complete • WBC cast -WBCs urinalysis
urinalysis correlation
• LE -Nitrite
correlation
• Protein -Bacteria Clinical • Renal tubular damage
significance

Clinical • Pyelonephritis
significance  Casts containing RTE cells represent the
presence of advanced tubular destruction,
producing urinary stasis along with disruption of
the tubular linings.
 Bacterial casts containing bacilli both within and  Similar to RTE cells, they are associated with
bound to the protein matrix are seen in heavy metal and chemical or drug-induced
pyelonephritis toxicity, viral infections, and allograft rejection.
 They may be pure bacterial casts or mixed with  They also accompany WBC casts in cases of
WBCs. pyelonephritis.
 Identification of bacterial casts can be difficult,  As discussed previously, the fibrils of Tamm-
because packed casts packed with bacteria can Horsfall protein that make up the cast matrix
resemble granular casts. remain attached to the RTE cells that produce
 Their presence should be considered when them; therefore, the observation of an
WBC casts and many free WBCs and bacteria occasional tubular cell attached to a hyaline
are seen in the sediment. cast can be expected.
 Confirmation of bacterial casts is best made by  They may be difficult to differentiate from
performing a Gram stain on the dried or WBCs, particularly if degeneration has
cytocentrifuged sediment. occurred.
 Staining and the use of phase microscopy can
be helpful to enhance the nuclear detail needed
for identification
 Fragments of epithelial tissue may also be
attached to the cast matrix.
 Bilirubin-stained RTE cells are seen in cases of
hepatitis
Fatty Casts Granular Casts
Point of Description Point of Description
reference reference

Appearance Fat droplets and oval fat bodies Appearance Coarse and fine granules in a
attached to protein matrix cast matrix

Sources of • Clumps of small crystals

Sources of Fecal debris
Identification
Identification • Columnar RTE cells
error
error

Reporting • Average number per lpf

Reporting • Average number per lpf

Complete • Protein
Complete • Protein urinalysis
correlation • Cellular casts
urinalysis
• Free fat droplets
correlation • RBCs & WBCs
• Oval fat bodies
Clinical • Glomerulonephritis
Clinical • Nephrotic syndrome significance
• Pyelonephritis
significance
• Toxic tubular necrosis • Stress and exercise 0-2/lpf
• Diabetes mellitus
• Crush injuries  The origin of the granules in nonpathologic
conditions appears to be from the
lysosomes excreted by RTE cells during
 Fatty casts are seen in conjunction with oval fat normal metabolism.
bodies and free fat droplets in disorders  It is not unusual to see hyaline casts
causing lipiduria. containing one or two of these granules.
 They are most frequently associated with the  Scanning electron microscope studies have
nephrotic syndrome, but are also seen in toxic confirmed that granular casts seen in
tubular necrosis, diabetes mellitus, and crush conjunction with WBC casts contain WBC
injuries. granules of varying sizes.
 Fatty casts are highly refractile under bright-  Urinary stasis allowing the casts to remain
field microscopy. The cast matrix may contain in the tubules must be present for granules
few or many fat droplets, and intact oval fat to result from disintegration of cellular casts.
bodies may be attached to the matrix  Granular casts occurring as a result of
 Confirmation of fatty casts is performed using cellular disintegration may contain an
polarized microscopy and Sudan III or Oil Red occasional recognizable cell.
O fat stains.  When granular casts remain in the tubules
 As discussed previously, cholesterol for extended periods, the granules further
demonstrates characteristic Maltese cross disintegrate, and the cast matrix develops a
formations under polarized light, and waxy appearance.
triglycerides and neutral fats stain orange with
fat stains.
 Fats do not stain with Sternheimer-Malbin
stains.
- Used of polarizing microscope
Waxy Casts Broad Casts
Point of Description Point of Description
reference reference

Appearance • Highly refractile cast Appearance • Wider than normal cast

with jagged ends and matrix
notches
Sources of • Fecal material, fibers
Sources of • Fibers and fecal material Identification
Identification error
error
Reporting • Average number per lpf
Reporting • Average number per lpf

Complete • Protein
Complete • Protein
urinalysis
urinalysis • WBCs & RBCs
correlation • Cellular casts correlation
• Granular casts
• Granular casts
• Waxy casts
• WBCs & RBCs
Clinical • Extreme urine stasis
Clinical • Stasis of urine flow
significance
significance • Renal failure
• Chronic renal failure

 End of all cast (Hyaline - beginning)

 The brittle, highly refractive cast matrix from
 Often referred to as renal failure casts, broad
which these casts derive their name is believed
casts like waxy casts represent extreme urine
to be caused by degeneration of the hyaline
stasis.
cast matrix and any cellular elements or
 As a mold of the distal convoluted tubules, the
granules contained in the matrix.
presence of broad casts indicates destruction
 Waxy casts are more easily visualized than
(widening) of the tubular walls.
hyaline casts because of their higher refractive
 Also, when the flow of urine to the larger
index.
collecting ducts becomes severely
 As a result of the brittle consistency of the cast
compromised, casts form in this area and
matrix, they often appear fragmented with
appear broad.
jagged ends and have notches in their sides
 All types of casts may occur in the broad form.
 With supravital stains, waxy casts stain a
 However, considering the accompanying
homogenous, dark pink.
urinary stasis, the most commonly seen broad
casts are granular and
 Bile-stained broad, waxy casts are seen as the
result of the tubular necrosis caused by viral
hepatitis
MICROSCOPIC EXAMINATION of URINE  The most common crystals seen in acidic urine
(Part 3) are urates, consisting of amorphous urates, uric
acid, acid urates, and sodium urates.
 Microscopically, most urate crystals appear
yellow to reddish brown and are the only normal
Urine Crystals crystals found in acidic urine that appear
colored.
 They may occur in clumps resembling granular
 Detect the presence of the relatively few casts.
abnormal types Amorphous urates
 liver disease
 inborn errors of metabolism  Amorphous urates are frequently encountered
 renal damage in specimens that have been refrigerated and
 Reporting: rare, few, moderate, or many per produce a very characteristic pink sediment.
hpf (Semiquantitative) – Normal  Accumulation of the pigment, uroerythrin, on
the surface of the granules is the cause of the
Abnormal crystals  average number per lpf pink color.
 Amorphous urates are found in acidic urine with
a pH greater than 5.5, whereas uric acid
 Formed by the precipitation of urine solutes crystals can appear when the pH is lower.
 Subject to: changes in temperature, solute
Uric acid
concentration, and pH (affect solubility)
 Rapidly precipitates at low temperature  Uric acid crystals are seen in a variety of
 Presence of crystals in fresh urine high sp. shapes, including rhombic, four-sided flat plates
Gr. (whetstones), wedges, and rosettes. They
 pH  determine type of crystal present usually appear yellow-brown, but may be
colorless and have a six-sided shape, similar to
*Organic & iatrogenic compounds  ppts. cystine crystals
In acidic pH  Uric acid crystals are highly birefringent under
*inorganic salts  ppts in neutral & alkaline sol’n polarized light, which aids in distinguishing
them from cystine crystals
*except: CaOx  ppts in acidic & neutral urine  Increased amounts of uric acid crystals,
particularly in fresh urine, are associated with
increased levels of purines and nucleic acids
Normal Crystal Seen in Acidic Urine and are seen in patients with leukemia who are
receiving chemotherapy, in patients with Lesch-
Crystal Color & Shape Solubility Nyhan syndrome and, sometimes, in patients
with gout.
Uric Acid Yellow-brown Alkali Acid urates and Sodium urates
(rhombic/4- Soluble
sided/rosette)  Acid urates and sodium urates are rarely
encountered and, like amorphous urates, are
Amorphous Brick dust or Alkali and seen in less acidic urine.
urates yellow brown heat  They are frequently seen in conjunction with
granules amorphous urates and have little clinical
significance.
Calcium Colorless Dilute HCl  Acid urates appear as larger granules and may
oxalate (envelopes, oval, have spicules similar to the ammonium biurate
[Acid/neutral dumbbell, crystals seen in alkaline urine. Sodium urate
(alkaline)] octahedral) crystals are needle-shaped and are seen in
synovial fluid during episodes of gout, but do
appear in the urine.
Calcium oxalate Normal Crystal Seen in Neutral/
 Calcium oxalate crystals are frequently seen in Alkaline Urine
acidic urine, but they can be found in neutral
urine and even rarely in alkaline urine.
 The most common form of calcium oxalate Crystal Color & Shape Solubility
crystals is the dihydrate that is easily
recognized as a colorless, octahedral envelope
or as two pyramids joined at their bases Amorphous White–colorless Dilute acetic
 Less characteristic and less frequently seen is phosphates (granular/white acid
the monohydrate form Monohydrate calcium ppt)
oxalate crystals are oval or dumbbell shaped.
 Both the dihydrate and monohydrate forms are
birefringent under polarized light.
 This may be helpful to distinguish the
monohydrate form from nonpolarizing RBCs.
 Calcium oxalate crystals are sometimes seen in Calcium Colorless (flat Dilute acetic
clumps attached to mucous strands and may phosphate rectangular acid
resemble casts. plates/thin prisms
 The finding of clumps of calcium oxalate often in rosette
crystals in fresh urine may be related to the formations)
formation of renal calculi, because the majority
of renal calculi are composed of calcium
oxalate.
 They are also associated with foods high in
oxalic acid, such as tomatoes and asparagus,
and ascorbic acid, because oxalic acid is an
end product of ascorbic acid metabolism.  Phosphates represent the majority of the
 The primary pathologic significance of calcium crystals seen in alkaline urine and include
oxalate crystals is the very noticeable presence amorphous phosphate, triple phosphate, and
of the mono-hydrate form in cases of ethylene calcium phosphate.
glycol (antifreeze) poisoning.  Other normal crystals associated with alkaline
 Massive amounts of crystals are frequently urine are calcium carbonate and ammonium
produced in these cases. biurate.

Amorphous phosphates
 Amorphous phosphates are granular in
appearance, similar to amorphous urates
 When present in large quantities following
specimen refrigeration, they cause a white
precipitate that does not dissolve on warming.
 They can be differentiated from amorphous
urates by the color of the sediment and the
urine pH.

Calcium phosphate
 Calcium phosphate crystals are not frequently
encountered.
 They may appear as colorless, flat rectangular
plates or thin prisms often in rosette formations.
 The rosette forms mayin the neutral range.
 Calcium phosphate crystals dissolve in dilute  They are frequently described as “thorny
acetic acid and sulfonamides do not. apples” because of their appearance as
 They have no clinical significance, though spicule-covered spheres
calcium phosphate is a common constituent of  Except for their occurrence in alkaline urine,
renal calculi. ammonium biurate crystals resemble other
urates in that they dissolve at 60°C and convert
to uric acid crystals when glacial acetic acid is
Normal Crystal Seen in Alkaline Urine added.
 Ammonium biurate crystals are almost always
Crystal Color & Shape Solubility encountered in old specimens and may be
associated with the presence of the ammonia
produced by urea-splitting bacteria.
Triple Colorless (prism shape Dilute
phosphate “coffin lids”) acetic acid Calcium carbonate
 Calcium carbonate crystals are small and
colorless, with dumbbell or spherical shapes
 They may occur in clumps that resemble
Ammonium Yellow-brown (spicule- Acetic acid amorphous material, but they can be
biurate covered spheres with heat distinguished by the formation of gas after the
“thorny apples”) addition of acetic acid.
 They are also birefringent, which differentiates
them from bacteria.
 Calcium carbonate crystals have no clinical
significance.
Calcium Colorless Gas from
carbonate (dumbbells/spherical) acetic acid

Triple phosphate
 Triple phosphate (ammonium magnesium
phosphate) crystals are commonly seen in
alkaline urine.
 In their routine form, they are easily identified
by their prism shape that frequently resembles
a “coffin lid”
 As they disintegrate, the crystals may develop a
feathery appearance.
 Triple phosphate crystals are birefringent under
polarized light. They have no clinical
significance; however, they are often seen in
highly alkaline urine associated with the
presence of urea-splitting bacteria

Ammonium biurate
 Ammonium biurate crystals exhibit the
characteristic yellow-brown color of the urate
crystals seen in acidic urine.
Abnormal Crystals seen in Acid Urine  Disintegrating forms may be seen in the
presence of ammonia.
Crystal/ Color/ Comment Solubility  They may be difficult to differentiate from
shape colorless uric acid crystals.
 Uric acid crystals are very birefringent under
Cystine  Cystinuria  Ammonia, polarized microscopy, whereas only thick
metabolic dilute HCl cystine crystals have polarizing capability.
 Colorless  Positive confirmation of cystine crystals is made
disorder of
 Hexagonal renal tubules using the cyanide-nitroprusside test
plates
 Confirmation Cholesterol Crystals
test 
cyanide-  Cholesterol crystals are rarely seen unless
nitroprusside specimens have been refrigerated, because the
test lipids remain in droplet form.
 However, when observed, they have a most
Cholesterol Seen in Chloroform characteristic appearance, resembling a
refrigerated rectangular plate with a notch in one or more
 Colorless specimen corners
notched (droplet form  They are associated with disorders producing
plates lipids) lipiduria, such as the nephrotic syndrome, and
are seen in conjunction with fatty casts and oval
Nephrotic fat bodies.
syndrome  Cholesterol crystals are highly birefringent with
polarized light
Radiographic Dye Crystals
Abnormal Urine Crystals
 Crystals of radiographic contrast media
 Abnormal urine crystals are found in acidic have a very similar appearance to
urine or rarely in neutral urine. cholesterol crystals and also are highly
 Most abnormal crystals have very characteristic birefringent.
shapes.  Differentiation is best made by comparison
 However, their identity should be confirmed by of the other urinalysis results and the patient
chemical tests or by patient information history.
(medications).  As mentioned previously, cholesterol
 Iatrogenic crystals can be caused by a variety crystals should be accompanied by other
of compounds, particularly when they are lipid elements and heavy proteinuria.
administered in high concentrations.  Likewise, the specific gravity of a specimen
 They may be of clinical significance when they containing radiographic contrast media is
precipitate in the renal tubules. markedly elevated when measured by
 The most commonly encountered iatrogenic refractometer.
crystals are discussed in this section.
Cystine Crystals
 Cystine crystals are found in the urine of
persons who inherit a metabolic disorder that
prevents reabsorption of cystine by the renal
tubules (cystinuria).
 Persons with cystinuria have a tendency to form
renal calculi, particularly at an early age.
 Cystine crystals appear as colorless, hexagonal
plates and may be thick or thin
Abnormal Crystals seen in
Acid/Neutral Urine
Crystal/Color Comments Solubility
Crystal/Color Comments Solubility
Sulfonamides  Seen in Acetone
Leucine Crystals Hot alkali or inadequate
Associated alcohol  Varied
patient
Yellow-brown (olorless to
With Liver hydration
yellow-brown)
Spheres Disorders  possibility of
 Needles,
(concentric tubular
Presence should rhombics,
circles and radial damage if
be accompanied whetstones,
striations) crystals are
by tyrosine sheaves of
forming in
crystals wheat, and
the nephron
rosettes

Tyrosine seen in Alkali or Ampicillin  Seen in Refrigera-

conjunction with heat massive
Colorless–yellow  Colorless tion forms
leucine crystals doses of this
 needles (form penicillin
bundles
Fine needle in specimens
bundles compound
(clump or rosette with positive
following without
form) chemical test
refrigeration adequate
results for
bilirubin hydration

May be
encountered in
inherited
disorders of
amino-acid
metabolism

Crystal/Color Comments Solubility

Bilirubin  present in Acetic acid,

hepatic HCl, NaOH,
Yellow
disorders ether,
 clumped  positive chloroform
needles or chemical test
granules result for
bilirubin
would be
expected

Radiographic  Markedly 10% NaOH

dye high specific
gravity when
 Colorless
measured by
 Cholesterol refractometer
crystal like
Tyrosine crystals diazo reaction can be performed for further
confirmation.
 Tyrosine crystals appear as fine colorless to
yellow needles that frequently form clumps or Ampicillin Crystals
rosettes
 Precipitation of antibiotics is not frequently
 They are usually seen in conjunction with
encountered except for the rare observation of
leucine crystals in specimens with positive
ampicillin crystals following massive doses of
chemical test results for bilirubin.
this penicillin compound without adequate
 Tyrosine crystals may also be encountered in
hydration.
inherited disorders of amino-acid metabolism
 Ampicillin crystals appear as colorless needles
that tend to form bundles following refrigeration
Leucine crystals  Knowledge of the patient’s history can aid in the
identification.
 Leucine crystals are yellow-brown spheres that
demonstrate concentric circles and radial
striations
 They are seen less frequently than tyrosine
crystals and, when present, should be
accompanied by tyrosine crystals.
Bilirubin crystals
 Bilirubin crystals are present in hepatic
disorders producing large amounts of bilirubin
in the urine.
 They appear as clumped needles or granules
with the characteristic yellow color of bilirubin
 A positive chemical test result for bilirubin would
be expected. In disorders that produce renal
tubular damage, such as viral hepatitis, bilirubin
crystals may be found incorporated into the
matrix of cast
Sulfonamide Crystals
 Prior to the development of more soluble
sulfonamides, the finding of these crystals in
the urine of patients being treated for UTIs was
common.
 Inadequate patient hydration was and still is the
primary cause of sulfonamide crystallization.
 The appearance of sulfonamide crystals in
fresh urine can suggest the possibility of tubular
damage if crystals are forming in the nephron.
 A variety of sulfonamide medications are
currently on the market; therefore, one can
expect to encounter a variety of crystal shapes
and colors. Shapes most frequently
encountered include needles, rhombics,
whetstones, sheaves of wheat, and rosettes
with colors ranging from colorless to yellow-
brown
 A check of the patient’s medication history aids
in the identification confirmation. If necessary, a
Urinary Sediment Artifacts Urinary Sediment Artifacts
 Contaminants of all types can be found in urine,
Artifact Comments particularly in specimens collected under
improper conditions or in dirty containers. The
Starch Granule  From cornstarch most frequently encountered artifacts include
used as glove starch, oil droplets, air bubbles, pollen grains,
 Resemble fat droplets
powder fibers, and fecal contamination.
when polarized
 Highly refractile  Because artifacts frequently resemble
 Dimpled center pathologic elements such as RBCs and casts,
sphere
artifacts can present a major problem to
Oil Droplets  highly refractile and students.
may resemble  They are often very highly refractile or occur in
From OIO contamination a different microscopic plane than the true
RBCs
sediment constituents. The reporting of artifacts
Air Bubbles is not necessary.
 occur when the Starch granule
specimen is placed
under a cover slip  Starch granule contamination may occur when
cornstarch is the powder used in powdered
gloves.
 The granules are highly refractile spheres,
usually with a dimpled center
 They resemble fat droplets when polarized,
Artifact Comments
producing a Maltese cross formation.
 Starch granules may also occasionally be
Pollen grains spheres with a cell wall confused with RBCs.
and occasional  Differentiation between starch and pathologic
 Concentric circles concentric circles elements can be made by considering other
urinalysis results, including chemical tests for
blood or protein and the presence of oval fat
bodies or fatty casts.

Hair and fibers from Oil droplets and air bubbles

mistaken for casts
clothing and diapers usually much longer  Oil droplets and air bubbles also are highly
and more refractile refractile and may resemble RBCs to
inexperienced laboratory personnel.
 Oil droplets may result from contamination by
immersion oil or lotions and creams
 Air bubbles occur when the specimen is placed
Fecal Artifacts presence of a fistula under a cover slip.
between the intestinal  The presence of these artifacts should be
 variety of sizes and and urinary tracts
shapes considered in the context of the other urinalysis
appear as plant and results.
meat fibers or as Pollen grains
brown amorphous
material  Pollen grains are seasonal contaminants that
appear as spheres with a cell wall and
occasional concentric circles
 Like many artifacts, their large size may cause
them to be out of focus with true sediment
constituents.
Hair and Fibers
 Hair and fibers from clothing and diapers may
initially be mistaken for, though they are usually
much longer and more refractile.
 Examination under polarized light can
frequently differentiate between fibers and casts
 Fibers often polarize, whereas, casts, other
than fatty casts, do not.
Fecal artifacts
 Improperly collected specimens or rarely the
presence of a fistula between the intestinal and
urinary tracts may produce fecal specimen
contamination.
 Fecal artifacts may appear as plant and meat
fibers or as brown amorphous material in a
variety of sizes and shapes