NORMAL CRYSTALS

Crystals Ph of urine Identification Remarks

Uric acid Acidic  Barrels, rosettes, rhomboids, needles or hexagonal Urate nephrolithiasis or acute urate nephropathy,
plates gout and leukemia
 Amber in color
 Soluble in alkali

Calcium oxalate Acidic or  Can be bihydrate (envelope shape) or monohydrate Dietary oxalate ingestion (spinach, tomato, cabbage
alkaline (ovoids, dumbells or rods) and asparagus) and nephrolithiasis

Calcium Alkaline  Large, flat shaped plates or wedge shaped prisms In rare cases, could be caused by
phosphate  Prisms often appear in rosettes hypoparathyroidism

Triple Alkaline  Coffin lid appearance In patients with struvite stones and in urinary tract
phosphate  Made of magnesium ammonium and phosphate infection with Proteus

Calcium Alkaline  Spheroids with radial striations Normal

carbonate  Colorless to yellow-brown
 Readily observed at low magnification
Ammonium Alkaline  Thorn apple appearance Old or longstanding urine sample
biurate  Yellow-brown with irregular protrusions or spiky
thorns

Amorphous Phosphates -  Fine granular material with no definite shape Can be confused with degenerating cells
seen in  Differentiated based on pH
alkaline urine
and soluble in
acetic acid

Abnormal crystals
Crystals Ph of urine Identification Remarks
Bilirubin Acidic  Needle-like or granular crystals Associated with increased conjugated bilirubin,
 Dark brown in color severe liver disorders of obstructive cause

Cholesterol Acidic  Colorless and refractile with notched corners Nephrotic syndrome
 Step ladder pattern
 Soluble in alcohol

Cysteine Acidic  Monomorphic, colorless, hexagonal plates that Genetic disease - cysteinuria (Nephrol Ther
resemble benzene rings 2015;11:174)
 Soluble in alkali, especially ammonia

Leucine Acidic / neutral  Concentric circles with radial striations Liver disorders with impaired amino acid
 Yellow-brown in color metabolism
 Resembles a cross section of a tree trunk
  Soluble in alkali

Tyrosine Acidic / neutral  Colorless, yellow fine needles Liver disorders with impaired amino acid
metabolism

Sulfonamide Acidic / neutral  Sheaves of small needles or spheroids Drug related

 Soluble in acetone

Noncellular casts
Type of cast Appearance Remarks
Hyaline  Appear colorless Seen normally (not associated with disease states); seen
 Cylindrical with parallel sides after strenuous exercise and with nonrenal diseases, such
 Made of Tamm-Horsfall mucoprotein with smooth as dehydration
texture and a refractive index very close to that of
the surrounding fluid
Granular  Composed of degenerated cellular debris, mainly Seen in acute glomerulonephritis and pyelonephritis;
of renal tubular epithelial cells embedded in appears muddy brown in acute tubular necrosis
Tamm-Horsfall protein

Waxy  Formed due to prolonged stasis of hyaline casts Final stage of cast degeneration: indicates tubular injury of
 Homogenous glassy appearance, with serrated a more chronic nature than granular or cellular casts and
margins is likely associated with low urine flow; always of
 Ends are straight and sharp, unlike other casts pathologic significance (associated with end stage renal
failure)

Fatty  Cylindrical structures mainly comprised of fat Seen in nephrotic syndrome; may represent tubular
globules and lipid droplets within a protein matrix degeneration

Cellular casts
Type of cast Appearance Remarks
White blood  Cylindrical structures mainly comprised of Comprised of neutrophils and seen in
cell (WBC) WBCs embedded in protein matrix tubulointerstitial diseases, such as acute
pyelonephritis; indicates focus of infection
as kidney
Epithelial  Composed of renal epithelial cells Seen in acute tubular necrosis, viral diseases (such as
infection with cytomegalovirus) and exposure to
nephrotoxic substances (such as mercury, ethylene glycol
and various drugs [with the same conditions as when
associated with renal epithelial cells]); closely resembles
granular casts

Red blood cell  Formed when RBCs are trapped in mucoprotein Presence of even a single cast is significant and indicates
(RBC) / matrix intrarenal hemorrhage, glomerulonephritis, acute tubular
hemoglobin  Degeneration of blood cells within cast matrix necrosis or renal ischemia
forms hemoglobin cast (red-brown color)

Cell type Description Remarks

Renal tubular  Renal tubular cells from the renal pelvis, ureter or bladder Tubular damage (like acute tubular
epithelial (polyhedral, columnar or oval) necrosis) pyelonephritis, viral infection
 Have granular cytoplasm with a single, large, refractile, of kidney, allograft rejection and
eccentric nucleus salicylate or heavy metal poisoning
(Clin J Am Soc Nephrol 2010;5:402)

Transitional  Large and diamond or pear shaped (caudate cells) Seen after catheterization and in
epithelial transitional cell carcinoma

Squamous  Can be squamous cells lining from skin surface urethra Large numbers - urine is contaminated
epithelial  Large cells that are rectangular in shape with vaginal fluid
 Flat with abundant cytoplasm
 Small, central nucleus
White blood  Have lobed nuclei and granular cytoplasm Infection in either the upper or lower urinary tract or with
 10 - 15 μm in size acute glomerulonephritis, tubule interstitial nephritis
 Normal: 0 - 2/HPF
  Greater than 10/HPF or presence of clumps is
suggestive of urinary tract infection
Red blood  Disc shaped refractile structures about 7 μm in Seen in glomerular damage, tumors which erode the
size urinary tract anywhere along its length, kidney trauma,
 Crenated in concentrated urine and swollen in urinary tract stones, renal infarcts, acute tubular necrosis,
hypotonic urine upper and lower urinary tract infections, nephrotoxins and
 Theoretically no RBCs must be seen; if 1 or more physical stress
red cells can be found in every HPF and if
contamination can be ruled out, the specimen is RBCs may contaminate the urine from the vagina in
probably abnormal menstruating women or from trauma produced by bladder
 Note: to differentiate - adding acetic acid to the catheterization
sediment lyses the RBCs and leaves behind
yeast, oil droplets and air bubbles > 80% of dysmorphic RBCs indicate glomerular disease
(e.g., acute glomerulonephritis)
Oval fat body  Desquamated tubular epithelial cells laden with fat Seen in nephrotic syndrome

Organism Description Remarks

Bacteria  Escherichia coli and Klebsiella In a wet preparation, presence of bacteria should be
pneumoniae are the most common bacteria reported only when urine is fresh; presence of only
found bacteria without pus cells indicates contamination
 Cocci or rods with vaginal or skin flora

Yeast cells  Round or oval structures of approximately the Seen in immunocompromised state, vaginal
same size as red blood cells candidiasis or diabetes mellitus
 In contrast to red cells, yeast cells show
budding, are oval, are more refractile and are
not soluble in 2% acetic acid
Trichomonas vaginalis  Motile organisms with pear shape, undulating Causes vaginitis in females and are thus
membrane on 1 side and 4 flagella contaminants in urine
 Easily detected in fresh urine due to their
motility Note: wet preparation of genital secretions or wet
mount is the diagnostic method of choice (Sci Rep
2019;9:11074)
 Schistosoma  Ova are elongated and are 60 x 160 microns Rarely seen in urine
haematobium  They are slightly transparent and have a
delicate, terminal spine

Enterobius  Ova are ovoid in shape and smooth with 1 Not a urinary parasite; can be present in the urine
vermicularis (pinworm) side flattened sediment as a fecal contaminant

 Miscellaneous
Element Description Remarks
Sperm Appears immotile in urine as it cannot Significant in infertility cases and sexual abuse
survive
May be seen in males after a nocturnal emission or ejaculation

Presence in the urine is of significance in the case of retrograde ejaculation