212 Part Two | Urinalysis

7. McPherson, RA, Ben-Ezra, J, Zhao S.: Basic examination of 16. Schumann, GB: Utility of urinary cytology in renal diseases.
urine. Henry’s Clinical Diagnosis and Management by Labora- Semin Nephrol 5(34) Sept, 1985.
tory Methods. Eds. McPherson, RA, Pincus, MR. 22nd Ed. 17. Graber, M, et al: Bubble cells: Renal tubular cells in the urinary
Philadelphia: Elsevier Saunders, 2011, p.465. sediment with characteristics of viability. J Am Soc Nephrol
8. Olympus Microscopy Resource Center: Specialized Microscopy 1(7):999–1004, 1991.
Techniques: Fluorescence. Web site: http://www.olympusmicro. 18. Baer, DM: Tips from clinical experts: Reporting of spermatozoa
com/primer/techniques/fluorescence/fluorhome.html. Accessed in microscopic urine exams. MLO 12:12, 1997.
May 10, 2019. 19. Bleyer, AJ, and Stanislav, K: Tamm Horsfall Glycoprotein and
9. Simpson, LO: Effects of normal and abnormal urine on red cell Uromodulin: It is All about the Tubules! Clin J Am Soc Nephrol.
shape. Nephron 60(3):383–384, 1992. 2016 Jan 7; 11(1): 6-8. Doi: 10.2215/CJN.12201115. Web site:
10. Stapleton, FB: Morphology of urinary red blood cells: A simple https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4702239.
guide in localizing the site of hematuria. Pediatr Clin North Am Accessed May 11, 2019.
34(3):561–569, 1987. 20. Kumar, S, and Muchmore, A: Tamm-Horsfall protein—
11. Fassett, EG, et al: Urinary red cell morphology during exercise. Uromodulin, 1950–1990. Kidney Int 37:1395–1399, 1990.
Am J Clin Pathol 285(6353):1455–1457, 1982. 21. Haber, MH: Urinary Sediment: A textbook Atlas. American
12. Kohler, H, Wandel, E, and Brunch, B: Acanthocyturia: A Society of Clinical Pathologists, Chicago, 1981.
characteristic marker for glomerular bleeding. Int Soc Nephrol 22. Lindner, LE, and Haber, MH: Hyaline casts in the urine:
40:115–120, 1991. Mechanism of formation and morphological transformations.
13. Tomita, M, et al: A new morphological classification of urinary Am J Clin Pathol 80(3):347–352, 1983.
erythrocytes for differential diagnosis of hematuria. Clin 23. Lindner, LE, Jones, RN, and Haber, MH: A specific cast in acute
Nephrol 37(2):84–89, 1992. pyelonephritis. Am J Clin Pathol 73(6):809–811, 1980.
14. Haber, MH, Lindner, LE, and Ciofalo, LN: Urinary casts after 24. Haber, MH, and Lindner, LE: The surface ultrastructure of
stress. Lab Med 10(6):351–355, 1979. urinary casts. Am J Clin Pathol 68(5):547–552, 1977.
15. Corwin, HL, Bray, RA, and Haber, MH: The detection and 25. Linder, LE, Vacca, D, and Haber, MF: Identification and
interpretation of urinary eosinophils. Arch Pathol Lab Med composition of types of granular urinary cast. Am J Pathol
113:1256–1258, 1989. 80(3):353–358, 1983.

Study Questions
1. Macroscopic screening of urine specimens is used to: 5. When using the glass-slide and cover-slip method,
A. Provide results as soon as possible which of the following might be missed if the cover slip
is overflowed?
B. Predict the type of urinary casts present
A. Casts
C. Increase cost-effectiveness of urinalysis
B. RBCs
D. Decrease the need for polarized microscopy
C. WBCs
2. Variations in the microscopic analysis of urine include all
D. Bacteria
of the following except:
A. Preparation of the urine sediment 6. Initial screening of the urine sediment is performed using
an objective power of:
B. Amount of sediment analyzed
A. 4×
C. Method of reporting
B. 10×
D. Identification of formed elements
C. 40×
3. All of the following can cause false-negative microscopic
D. 100×
results except:
A. Braking the centrifuge 7. Which of the following should be used to reduce light
intensity in bright-field microscopy?
B. Failing to mix the specimen
A. Centering screws
C. Diluting alkaline urine
B. Aperture diaphragm
D. Using midstream clean-catch specimens
C. Rheostat
4. The two factors that determine relative centrifugal force
D. Condenser aperture diaphragm
are:
A. Radius of rotor head and RPM 8. Which of the following are reported as number per lpf?
B. Radius of rotor head and time of centrifugation A. RBCs
C. Diameter of rotor head and RPM B. WBCs
D. RPM and time of centrifugation C. Crystals
D. Casts
 Chapter 7 | Microscopic Examination of Urine 213

9. The Sternheimer-Malbin stain is added to urine 17. Leukocytes that stain pale blue with Sternheimer-Malbin
sediments to do all of the following except: stain and exhibit brownian movement are:
A. Increase visibility of sediment constituents A. Indicative of pyelonephritis
B. Change the constituents’ refractive index B. Basophils
C. Decrease precipitation of crystals C. Mononuclear leukocytes
D. Delineate constituent structures D. Glitter cells
10. Nuclear detail can be enhanced by: 18. Sometimes mononuclear leukocytes are mistaken for:
A. Prussian blue A. Yeast cells
B. Toluidine blue B. Squamous epithelial cells
C. Acetic acid C. Pollen grains
D. Both B and C D. Renal tubular cells
11. Which of the following lipids is/are stained by Sudan III? 19. When pyuria is detected in a urine sediment, the slide
A. Cholesterol should be checked carefully for the presence of:
B. Neutral fats A. RBCs
C. Triglycerides B. Bacteria
D. Both B and C C. Hyaline casts
D. Mucus
12. Which of the following lipids is/are capable of polarizing
light? 20. Transitional epithelial cells are sloughed from the:
A. Cholesterol A. Collecting duct
B. Neutral fats B. Vagina
C. Triglycerides C. Bladder
D. Both A and B D. Proximal convoluted tubule
13. The purpose of the Hansel stain is to identify: 21. The largest cells in the urine sediment are:
A. Neutrophils A. Squamous epithelial cells
B. Renal tubular cells B. Urothelial epithelial cells
C. Eosinophils C. Cuboidal epithelial cells
D. Monocytes D. Columnar epithelial cells
14. Crenated RBCs are seen in urine that is: 22. A squamous epithelial cell that is clinically significant
A. Hyposthenuric is the:
B. Hypersthenuric A. Cuboidal cell
C. Highly acidic B. Clue cell
D. Highly alkaline C. Caudate cell
D. Columnar cell
15. Differentiation among RBCs, yeast, and oil droplets may
be accomplished by all of the following except: 23. Forms of transitional epithelial cells include all of the
A. Observation of budding in yeast cells following except:
B. Increased refractility of oil droplets A. Spherical
C. Lysis of yeast cells by acetic acid B. Caudate
D. Lysis of RBCs by acetic acid C. Convoluted
D. Polyhedral
16. A finding of dysmorphic RBCs is indicative of:
A. Glomerular bleeding 24. Increased transitional cells are indicative of:
B. Renal calculi A. Catheterization
C. Traumatic injury B. Malignancy
D. Coagulation disorders C. Pyelonephritis
D. Both A and B
214 Part Two | Urinalysis

25. A primary characteristic used to identify renal tubular 33. A person submitting a urine specimen after a strenuous
epithelial cells is: exercise routine normally can have all of the following in
A. Elongated structure the sediment except:
B. Centrally located nucleus A. Hyaline casts
C. Spherical appearance B. Granular casts
D. Eccentrically located nucleus C. RBC casts
D. WBC casts
26. After an episode of hemoglobinuria, RTE cells may
contain: 34. Before identifying an RBC cast, all of the following
A. Bilirubin should be observed:
B. Hemosiderin granules A. Free-floating RBCs
C. Porphobilinogen B. Intact RBCs in the cast matrix
D. Myoglobin C. A positive reagent strip blood reaction
D. All of the above
27. The predecessor of the oval fat body is the:
A. Histiocyte 35. WBC casts are associated primarily with:
B. Urothelial cell A. Pyelonephritis
C. Monocyte B. Cystitis
D. Renal tubular cell C. Glomerulonephritis
D. Viral infections
28. A structure believed to be an oval fat body produced a
Maltese cross formation under polarized light but does 36. The shape of the RTE cell associated with RTE casts is
not stain with Sudan III. The structure: primarily:
A. Contains cholesterol A. Elongated
B. Is not an oval fat body B. Cuboidal
C. Contains neutral fats C. Round
D. Is contaminated with immersion oil D. Columnar
29. The finding of yeast cells in the urine is commonly 37. When observing RTE casts, the cells are primarily:
associated with: A. Embedded in a clear matrix
A. Cystitis B. Embedded in a granular matrix
B. Diabetes mellitus C. Attached to the surface of a matrix
C. Pyelonephritis D. Stained by components of the urine filtrate
D. Liver disorders
38. The presence of fatty casts is associated with:
30. The primary component of urinary mucus is: A. Nephrotic syndrome
A. Bence Jones protein B. Crush injuries
B. Microalbumin C. Diabetes mellitus
C. Uromodulin D. All of the above
D. Orthostatic protein
39. Nonpathogenic granular casts contain:
31. The majority of casts are formed in the: A. Cellular lysosomes
A. Proximal convoluted tubules B. Degenerated cells
B. Ascending loop of Henle C. Protein aggregates
C. Distal convoluted tubules D. Gram-positive cocci
D. Collecting ducts
40. All of the following are true about waxy casts except they:
32. Cylindruria refers to the presence of: A. Represent extreme urine stasis
A. Cylindrical renal tubular cells B. May have a brittle consistency
B. Mucus-resembling casts C. Require staining to be visualized
C. Hyaline and waxy casts D. Contain degenerated granules
D. All types of casts
 Chapter 7 | Microscopic Examination of Urine 215

41. Observation of broad casts represents: 48. Match the following crystals seen in alkaline urine with
A. Destruction of tubular walls their description/identifying characteristics:
B. Dehydration and high fever Triple phosphate 1. Yellow granules
C. Formation in the collecting ducts Amorphous phosphate 2. Thin prisms
D. Both A and C Calcium phosphate 3. “Coffin lids”
Ammonium biurate 4. Dumbbell shape
42. All of the following contribute to urinary crystals
formation except: Calcium carbonate 5. White precipitate
A. Protein concentration 6. Thorny apple
B. pH 49. Match the following abnormal crystals with their
C. Solute concentration description/identifying characteristics:
D. Temperature Cystine 1. Bundles after
refrigeration
43. The most valuable initial aid for identifying crystals in a
Tyrosine 2. Highly alkaline pH
urine specimen is:
Cholesterol 3. Bright yellow clumps
A. pH
Leucine 4. Hexagonal plates
B. Solubility
Ampicillin 5. Flat plates, high spe-
C. Staining
cific gravity
D. Polarized microscopy
Radiographic dye 6. Concentric circles,
44. Crystals associated with severe liver disease include all radial striations
of the following except: Bilirubin 7. Notched corners
A. Bilirubin 8. Fine needles seen in
B. Leucine liver disease
C. Cystine 50. Match the following types of microscopy with their
D. Tyrosine descriptions:
45. All of the following crystals routinely polarize except: Bright-field 1. Indirect light is reflected off
the object
A. Uric acid
Phase 2. Objects split light into two
B. Cholesterol
beams
C. Radiographic dye
Polarized 3. Low-refractive-index ob-
D. Cystine jects may be overlooked
46. Casts and fibers usually can be differentiated using: Dark-field 4. Three-dimensional images
A. Solubility characteristics Fluorescent 5. Forms halo of light around
B. Patient history object
C. Polarized light Interference 6. Detects electrons emitted
contrast from objects
D. Fluorescent light
7. Detects specific wave-
47. Match the following crystals seen in acidic urine with lengths of light emitted
their description/identifying characteristics: from objects
Amorphous urates 1. Envelopes
Uric acid 2. Thin needles
Calcium oxalate 3. Yellow-brown,
monohydrate whetstone
Calcium oxalate 4. Pink sediment
dihydrate 5. Ovoid
216 Part Two | Urinalysis

Case Studies and Clinical Situations

1. An 85-year-old woman with diabetes and a broken hip decreased renal concentrating ability. Urinalysis results are
has been confined to bed for the past 3 months. Results as follows:
of an ancillary blood glucose test are 250 mg/dL, and COLOR: Amber KETONES: Negative
her physician orders additional blood tests and a routine
CLARITY: Hazy BLOOD: Negative
urinalysis. The urinalysis report is as follows:
SP. GRAVITY: 1.010 BILIRUBIN: Large
COLOR: Pale yellow KETONES: Negative
pH: 7.0 UROBILINOGEN: 4.0 EU
CLARITY: Hazy BLOOD: Moderate
PROTEIN: 2+ NITRITE: Negative
SP. GRAVITY: 1.020 BILIRUBIN: Negative
GLUCOSE: Negative LEUKOCYTES: Negative
pH: 5.5 UROBILINOGEN: Normal
Microscopic:
PROTEIN: Trace NITRITE: Negative
2 to 4 WBCs/hpf 1 to 2 hyaline casts/lpf
GLUCOSE: 100 mg/dL LEUKOCYTES: 2+
1 to 3 RBCs/hpf 1 to 2 granular casts/lpf
Microscopic:
2 to 4 bile-stained RTE
20 to 25 WBCs/hpf
cells/hpf
Many yeast cells and hyphae
0 to 1 RTE casts/lpf
a. Why are yeast infections common in patients with dia-
0 to 1 bile-stained waxy
betes mellitus?
casts/lpf
b. With a blood glucose level of 250 mg/dL, should glu-
a. Based on the urinalysis results, in what area of the
cose be present in the urine? Why or why not?
nephron is damage occurring?
c. Is there a discrepancy between the negative nitrite and
b. Is this consistent with the patient’s primary diagnosis?
the positive leukocyte esterase results? Explain your
Explain your answer.
answer.
c. What is causing the RTE cells to be bile stained?
d. What is the major discrepancy between the chemical
and microscopic results? d. Why is the urobilinogen level elevated?
e. Considering the patient’s history, what is the most e. State a disorder in which the urobilinogen level would
probable cause for the discrepancy? be elevated but the bilirubin result would be negative.

2. A medical laboratory science student training in a newly 4. A 30-year-old woman being treated for a UTI brings a
renovated STAT laboratory is having difficulty performing urine specimen to the employee health clinic at 4:00 p.m.
a microscopic urinalysis. Reagent strip testing indicates The nurse on duty tells her that the specimen will be re-
the presence of moderate blood and leukocytes, but also frigerated and tested by the medical laboratory scientist
the student is observing some large unusual objects re- (MLS) the next morning. The MLS has difficulty inter-
sembling crystals and possible casts. In addition, the stu- preting the color of the reagent strip tests and reports
dent is having difficulty keeping all of the constituents in only the following results:
focus at the same time. COLOR: Amber CLARITY: Slightly cloudy
a. Why is the student having difficulty focusing? Microscopic:
b. What is a possible cause of the unusual microscopic 3 to 5 RBCs/hpf
constituents? 8 to 10 WBCs/hpf
c. Should the student be concerned about the unusual Moderate bacteria
microscopic constituents? Explain your answer.
Moderate colorless crystals appearing in bundles
d. What microscopy technique could be used to aid in
a. What could have caused the technologist to have diffi-
differentiating a cast and an artifact?
culty interpreting the results on the reagent strip?
3. A prisoner sentenced to 10 years for selling illegal drugs b. Could this specimen produce a yellow foam when
develops jaundice, lethargy, and hepatomegaly. A test for shaken?
hepatitis B surface antigen is positive, and the patient is
c. What could the technologist do to aid in the identifi-
placed in the prison infirmary. When his condition ap-
cation of the crystals?
pears to worsen and a low urinary output is observed, the
patient is transferred to a local hospital. Additional testing d. What is the probable identification of the colorless
detects a superinfection with delta hepatitis virus and crystals?
 Chapter 7 | Microscopic Examination of Urine 217

5. A 2-year-old left unattended in the garage for 5 minutes is SP. GRAVITY: 1.030 BILIRUBIN: Negative
suspected of ingesting antifreeze (ethylene glycol). The pH: 5.5 UROBILINOGEN: Normal
urinalysis has a pH of 6.0 and is negative on the chemical
PROTEIN: 2+ NITRITE: Negative
examination. Two distinct forms of crystals are observed
in the microscopic examination. GLUCOSE: Negative LEUKOCYTE: Negative
a. What type of crystals would you expect to be present? Microscopic:
b. What is the other form of this crystal? 0 to 3 WBCs/hpf
c. Describe the two forms. 0 to 4 hyaline casts/lpf
d. Which form would you expect to be predominant? 0 to 3 granular casts/lpf
Few squamous epithelial cells
6. A female patient comes to the outpatient clinic with
symptoms of UTI. She brings a urine specimen with her. a. Are these results of clinical significance?
Results of the routine analysis performed on this speci- b. Explain the discrepancy between the chemical and
men are as follows: microscopic blood results.
COLOR: Yellow KETONES: Negative c. What is the probable cause of the granular casts?
CLARITY: Hazy BLOOD: Small 8. As supervisor of the urinalysis section, you are reviewing
SP. GRAVITY: 1.015 BILIRUBIN: Negative results. State why or why not each of the following results
pH: 9.0 UROBILINOGEN: Normal would concern you.
PROTEIN: Negative NITRITE: Negative a. The presence of waxy casts and a negative protein in
urine from a 6-month-old girl
GLUCOSE: Negative LEUKOCYTE: 2+
b. Increased transitional epithelial cells in a specimen
Microscopic:
obtained after cystoscopy
1 to 3 RBCs/hpf Heavy bacteria
c. Tyrosine crystals in a specimen with a negative
8 to 10 WBCs/hpf Moderate squamous bilirubin test result
epithelial cells
d. Cystine crystals in a specimen from a patient
a. What discrepancies are present between the chemical diagnosed with gout
and microscopic test results?
e. Cholesterol crystals in urine with a specific gravity
b. State a reason for the discrepancies. greater than 1.040
c. Identify a chemical result in the urinalysis that con- f. Trichomonas vaginalis in a urine specimen from a male
firms your reason for the discrepancies. patient
d. What course of action should the laboratory take to g. Amorphous urates and calcium carbonate crystals in a
obtain accurate results for this patient? specimen with a pH of 7.0
7. A high school student is taken to the emergency room
with a broken leg that occurred during a football game.
The urinalysis results are as follows:
COLOR: Dark yellow KETONES: Negative
CLARITY: Hazy BLOOD: Moderate