10/1/2023

Contents:

 Preparation and Examination of the Urine Sediment

 Urinalysis Microscopic Techniques
 Sediments Constituents

Microscopic  Cast Composition and Formation and Clinical Significance

 Normal and Abnormal Crystals

Examination of Urine
 Urinary Artifacts

Week 7

Preparedby: Fe P. Lleno, DrPH

Macroscopic screening and Microscopic Correlation

Preparation and Examination of the
Screening Test Significance Urine Sediment
Color Blood
Clarity Hematuria versus Thomas Addis (1926)
hemoglobinuria/myoglobinuria Hemocytometer
Confirm pathologic or non-
pathologic cause of turbidity 12-hour specimen
RBCs, WBCs, casts, and epithelial cells
Blood RBCs/RBC casts used primarily to monitor the course of diagnosed
Protein Casts/cells cases of renal disease
Nitrite Bacteria/WBCs
Leukocyte esterase WBCs/WBC casts/bacteria
Glucose Yeast

Preparation of the Urine Sediment Examination of the Urine Sediment

 Freshly voided urine
Observe minimum of 10 fields [both low & high PF]
 midstream clean-catch specimen
LPF (10x) 
 10 and 15 mL (12ml) 
Centrifuged for 5 mins @ 400RCF
detect casts and to ascertain the general
composition of the sediment
 0.5-1.0 mL  left after decantation
HPF (40x) 
Represents urinary sediments
 Agitate Identification
 Place a drop (20 μL or 0.02 mL) of centrifuged urine in a slide + glass casts have a tendency to locate near the edges of
cover slip (22 X 22 mm ) the cover slip (LPF scanning around the cover slip
 Read microscopically perimeter)

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Examination of the Urine Sediment Examination of the Urine Sediment

 Bright field microscopy (unstained sediments) Reporting of Microscopic Sediments
 Artifacts are larger than urinary sediments Manner of Comment
Reporting
Reporting of Microscopic Sediments
Occasional 0-1, 0-3/HPF at 10 fields
Sediment Reporting Comment
Few 0-4, 2-5/HPF at 10 fields
Casts Lpf 10 fields
Some 3-5, 8-10/HPF at 10 fields
RBCs, WBCs Hpf
Moderate More than 10/HPF at 10 fields
Epithelial cells, Semi- rare, few, moderate, and
crystals, and quantitative many, or as 1+, 2+, 3+, and Many Abundant/HPF
other elements terms 4+, following laboratory
TNTC Too numerous to count (loaded)
format as to lpf or hpf use

Sediment Examination Techniques (Stains)

Stain Action Function

Sternheimer- Delineates structure Identifies WBCs,
Malbin (Crystal and contrasting epithelial cells, and
violet & Safranin colors of the nucleus casts
O) and cytoplasm
Toluidine blue Enhances nuclear Differentiates WBCs
(metachromatic detail and renal tubular
stain) epithelial (RTE) cells
2% acetic acid Lyses RBCs and Distinguishes RBCs
enhances nuclei of from WBCs, yeast,
WBCs oil droplets, and
crystals

Sediment Examination Techniques (Stains) Expected Staining Reactions of Sediment

Constituents
Stain Action Function
Elements in Usual Distinguishing Color of Comments
Lipid Stains: Oil Stains triglycerides Identifies free fat droplets Urinary Sediment Stained Elements
Red O and and neutral fats and lipid-containing cells RBCs Neutral—pink to purple
Sudan III orange-red and casts Acid—pink (unstained)
Gram stain Differentiates gram- Identifies bacterial casts Alkaline—purple
positive and gram- Hyaline casts Pale pink or pale purple Very uniform color;
negative bacteria slightly darker than
Hansel stain Methylene blue and Identifies urinary mucous threads
eosin Y stains eosinophils Coarse granular Dark purple granules in
eosinophilic granules inclusion casts purple matrix
Prussian blue Stains structures Identifies yellow-brown Finely granular Fine dark purple granules in
stain containing iron granules of hemosiderin in inclusion casts pale pink or pale purple
matrix
cells and casts

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Expected Staining Reactions of Sediment Expected Staining Reactions of Sediment

Constituents Constituents
Elements in Urinary Usual Distinguishing Color of Comments
Elements in Urinary Usual Distinguishing Comments
Sediment Stained Elements
Sediment Color of Stained
Nuclei Cytoplasm Elements
WBCs (dark-staining Purple Purple granules Waxy casts Pale pink or pale purple Darker than hyaline casts, but
cells) of a pale even color; distinct
Glitter cells Colorless or Pale blue or gray Some glitter broken ends
(Sternheimer- light blue cells exhibit Fat inclusion casts Fat globules unstained Rare; presence is confirmed if
Malbin positive brownian in a pink matrix examination under polarized
cells) movement light indicates double
Renal tubular Dark shade of Light shade of refraction
epithelial cells blue-purple blue-purple Red cell inclusion Pink to orange-red Intact cells can be seen in
Bladder tubular Blue-purple Light purple casts matrix
epithelial cells Blood (hemoglobin) Orange-red No intact cells
Squamous Dark shade of Light purple or casts
epithelial cells orange-purple blue

Expected Staining Reactions of Sediment

Constituents Cytodiagnostic Urine Testing
Elements in Urinary Usual Distinguishing Comments
Sediment Color of Stained preparation of permanent slides using
Elements cytocentrifugation
Bacteria Motile: do not stain Motile organisms are not
Nonmotile: stain impaired Staining with Papanicolaou stain
purple
Detection of malignancies of the lower urinary tract
Trichomonas Light blue-green Motility is unimpaired in fresh
vaginalis specimens when First morning specimen
recommended volumes of
stain are used; immobile
provides more definitive information about renal tubular
organisms also identifiable changes associated with transplant rejection; viral,
Mucus Pale pink or pale blue fungal, and parasitic infections; cellular inclusions;
Background Pale pink or pale pathologic casts; and inflammatory conditions
purple

Urinalysis Microscopic Techniques Urinalysis Microscopic Techniques

Technique Function Technique Function

Bright-field microscopy Used for routine urinalysis Dark-field microscopy Aids in identification of Treponema
pallidum
Phase-contrast Enhances visualization of elements with
microscopy low refractive indices, such as hyaline Fluorescence Allows visualization of naturally
casts, mixed cellular casts, mucous microscopy fluorescent microorganisms or those
threads, and Trichomonas stained by a fluorescent dye

Polarizing microscopy Aids in identification of cholesterol in Interference- contrast Produces a three-dimensional

oval fat bodies, fatty casts, and crystals microscopy-image and layer-by-layer
imaging of a specimen

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Sediment Constituents Sediment Constituents (RBC)

Red Blood Cell (RBC)
Point of reference Description
Appearance • Non-nucleated biconcave disks
• Crenated in hypertonic urine
• Ghost cells in hypotonic/hyposthenuric urine
• Dysmorphic with glomerular membrane damage
Sources of • Yeast cells
Identification • Oil droplets
error • Air bubbles

Reporting Average number per 10 hpfs

Complete • Color
urinalysis • Reagent strip blood reaction
correlation

Sediment Constituents White Blood Cell (WBC)

Point of reference Description
Appearance • Larger than RBCs (12μ diameter)
• Granulated, multilobed neutrophils
• Glitter cells in hypotonic urine
• Mononuclear cells with abundant cytoplasm

Sources of • Renal tubular epithelial cells

Identification error
Reporting Average number per 10 hpfs
Complete urinalysis • Leukocyte esterase
Clinical Significance correlation • Nitrite
The presence of RBCs in the urine is associated with damage • Specific gravity
to the glomerular membrane or vascular injury within the
genitourinary tract.
• pH

Sediment Constituents (WBC)

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Sediment Constituents
Epithelial Cells (Squamous) Squamous Epithelial Cell

Point of reference Description

Appearance • Largest cells in the sediment with
abundant, irregular cytoplasm and
prominent nuclei
Sources of • Rarely encountered, folded cells may
Identification error resemble casts
Reporting • Rare, few, moderate, or many per lpf
Complete urinalysis • Clarity
correlation

Sediment Constituents
Epithelial Cells (Transitional/Urothelial)
Point of reference Description
Appearance • Spherical, polyhedral, or caudate
with centrally located nucleus
Sources of • Spherical forms resemble RTE cells
Identification
error
Reporting • Rare, few, moderate, or many per
hpf
Complete • Clarity;
urinalysis • blood, if malignancy-associated
correlation

Sediment Constituents
Transitional (Urothelial) Epithelial Cells Epithelial Cells (Renal Tubular)
Point of reference Description
Appearance • Rectangular, columnar, round, oval or,
cuboidal with an eccentric nucleus possibly
bilirubin-stained or hemosiderin-laden
Sources of • Spherical transitional cells Granular casts
Identification
error
Reporting • Average number per 10 hpfs
Complete • Leukocyte esterase and nitrite (pyelonephritis)
urinalysis • Color *Clarity
correlation • Protein *Bilirubin (hepatitis)
• Blood

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Renal Tubular Epithelial Cells

Sediment Constituents Oval Fat Bodies

Oval Fat Bodies
Point of reference Description
Appearance • Highly refractile RTE cells
Sources of • Confirm with fat stains and polarized
Identification error microscopy

Reporting • Average number per hpf

Complete urinalysis • Clarity
correlation • Blood
• Protein
• Free fat droplets/fatty casts Sudan III-stained oval fat body (×400).

Sediment Constituents
Bacteria
Bacteria
Point of reference Description
Appearance • Small spherical and rod-shaped structures

Sources of • Amorphous phosphates and urates

Identification error
Reporting • Few, moderate, or many per hpf,
- the presence of WBCs may be required
Complete urinalysis • pH
correlation • Nitrite
• LE
• WBCs

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Sediment Constituents
Yeast
Yeast
Point of reference Description
Appearance • Small, oval, refractile structures with
buds and/or mycelia
Sources of • RBCs
Identification error
Reporting • Rare, few, moderate, or many per hpf,
the presence of WBCs may be required
Complete urinalysis • Glucose
correlation • LE
• WBCs

Sediment Constituents T. vaginalis - STP associated with

Parasites (Trichomonas) Parasites vaginal inflammation

- Asymptomatic - male urethra and
prostate

Point of Description
reference
Appearance • Pear-shaped, motile, flagellated

Sources of • WBCs
Identification • renal tubular epithelial cells
error
Reporting • Rare, few, moderate, or many Schistosoma haematobium ova
per hpf Eggs are often contained in the
last few drops of urine expelled
from the bladder
Complete • LE
urinalysis • WBCs Enterobius vermicularis ova - fecal contamination
correlation

Sediment Constituents Sediment Constituents

Spermatozoa Mucus
Point of reference Description Point of reference Description
Appearance • Single or clumped threads with a
Appearance • Tapered oval head with low refractive index
long, thin tail
Sources of • Hyaline casts
Sources of • None Identification error
Identification error
Reporting • Rare, few, moderate, or many per
Reporting • Present, based on lpf
laboratory protocol Complete • None
Complete urinalysis • Protein urinalysis
correlation correlation

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Mucus Urine Casts

Unique to kidney
Formed within the lumen of DCT & CD
Provides microscopic view of condition w/in nephron
Lpf  detection/Scanning around cover slip edge
cast matrix - low refractive index  observe in subdued
light
Reporting: Ave. #/10 lpf

Casts (Composition and Formation) Hyaline Casts

Point of reference Description
Tamm-Horsfall protein (glycoprotein excreted by the RTE cells of
the CDT and upper collecting ducts) Appearance • Colorless homogenous matrix
- major constituent of cast Sources of • Mucus, fibers, hair, increased lighting
Identification error
- stress & exercise
Reporting • Average number per lpf
Albumin, immunoglobulin Complete urinalysis • Protein -Blood (exercise)
Protein gel urine-flow stasis, acidity, Na+, Ca++ correlation • Color (exercise)
Tapered end  formed at the junction of ALH & DCT Clinical significance • Glomerulonephritis
• Pyelonephritis
-cylindroids • Chronic renal disease
Cylindruria  presence of urinary cast • Congestive heart failure
• Stress and exercise

Hyaline Casts RBC Casts

Point of reference Description
Appearance • Orange-red color, cast matrix
containing RBCs
Sources of • RBC clumps
Identification error
Reporting • Average number per lpf
Complete • RBCs
urinalysis • Blood
correlation • Protein
Clinical • Glomerulonephritis
significance • Strenuous exercise

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RBC Casts
WBC Casts
Disintegrating RBC cast.
Point of reference Description
Appearance • Cast matrix containing WBCs

Granular, dirty, brown cast (

Sources of • WBC clumps
Identification error
Reporting • Average number per lpf
Complete urinalysis • WBCs Protein LE
correlation
Clinical significance • Pyelonephritis
• Acute interstitial nephritis

Cast containing hemoglobin pigment. A

WBC Casts
Bacterial Casts

Point of reference Description

Appearance • Bacilli bound to protein matrix
Sources of • Granular casts
Identification error
Reporting • Average number per lpf
Complete • WBC cast -WBCs
urinalysis • LE -Nitrite
correlation • Protein -Bacteria
Clinical • Pyelonephritis
significance

Epithelial Cell Casts Epithelial Cell Casts

Point of reference Description
Appearance • RTE cells attached to protein matrix
Sources of • WBC cast
Identification error
Reporting • Average number per lpf
Complete • Protein RTE cells
urinalysis
correlation
Clinical • Renal tubular damage
significance

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Fatty Casts Fatty Casts

Point of reference Description
Appearance Fat droplets and oval fat bodies
attached to protein matrix
Sources of Fecal debris
Identification error
Reporting • Average number per lpf
Complete • Protein
urinalysis • Free fat droplets
correlation • Oval fat bodies
Clinical • Nephrotic syndrome
significance • Toxic tubular necrosis
• Diabetes mellitus -Crush injuries

Granular Casts Granular Casts

Point of reference Description
Appearance Coarse and fine granules in a cast
matrix
Sources of • Clumps of small crystals
Identification error • Columnar RTE cells
Reporting • Average number per lpf
Complete urinalysis • Protein
correlation • Cellular casts
• RBCs & WBCs
Clinical • Glomerulonephritis
significance • Pyelonephritis
• Stress and exercise

Waxy Casts Waxy Casts

Point of reference Description
Appearance • Highly refractile cast with jagged ends
and notches
Sources of • Fibers and fecal material
Identification error
Reporting • Average number per lpf
Complete urinalysis • Protein
correlation • Cellular casts
• Granular casts
• WBCs & RBCs
Clinical • Stasis of urine flow
significance • Chronic renal failure

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Broad Casts Urine Crystals

Point of reference Description
detect the presence of the relatively few
Appearance • Wider than normal cast matrix
abnormal types
Sources of • Fecal material, fibers
Identification error -liver disease
Reporting • Average number per lpf -inborn errors of metabolism
Complete • Protein -renal damage
urinalysis • WBCs & RBCs
correlation • Granular casts Reporting: rare, few, moderate, or many per hpf
• Waxy casts
Clinical • Extreme urine stasis Abnormal crystals  average number per lpf
significance • Renal failure

Urine Crystals Normal Crystal Seen in Acidic Urine

 formed by the precipitation of urine solutes
Crystal Color & Shape Solubility Appearnce
 Subject to: changes in temperature, solute concentration, and
pH (affect solubility) Uric Acid Yellow-brown Alkali
(rhombic/4- Soluble
 Rapidly precipitates at low temperature
sided/rosette)
 Presence of crystals in fresh urine  high sp. Gr.
Amorphous Brick dust or Alkali and
 pH  determine type of crystal present urates yellow brown heat
*Organic & iatrogenic compounds  ppts. In acidic pH granules
*inorganic salts  ppts in neutral & alkaline sol’n Calcium Colorless Dilute HCl
*except: CaOx  ppts in acidic & neutral urine oxalate (envelopes, oval,
[Acid/neutral dumbbell,
(alkaline)] octahedral)

Uric acid crystal Amorphous urates

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Calcium oxalate Normal Crystal Seen in Neutral/Alkaline Urine

Crystal Color & Shape Solubility Appearnce

Amorphous White–colorless Dilute acetic
phosphates (granular/white acid
ppt)

Calcium Colorless (flat Dilute acetic

phosphate rectangular acid
plates/thin prisms
often in rosette
formations)

Amophous phosphate Calcium phosphate

Normal Crystal Seen in Alkaline Urine Triple phosphate (STRUVITE)

Crystal Color & Shape Solubility Appearnce
Triple Colorless (prism Dilute acetic
phosphate shape “coffin lids”) acid

Ammonium Yellow-brown Acetic acid

biurate (spicule-covered with heat
spheres “thorny
apples”)

Calcium Colorless Gas from

carbonate (dumbbells/spheric acetic acid
al)

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Ammonium biurate Calcium carbonate

Abnormal Crystals seen in Acid Urine Abnormal Crystals seen in Acid Urine
Crystal/Color Comment Solubility Appearnce Crystal/Color Comments Solubility Appearance
/shape • present in Acetic acid,
Bilirubin
Cystine • Cystinuria  Ammonia, • Yellow hepatic disorders HCl, NaOH,
• Colorless metabolic dilute HCl • clumped • positive ether,
• Hexagonal disorder of renal needles or chemical test chloroform
plates tubules
granules result for bilirubin
• Confirmation test
 cyanide- would be
nitroprusside test expected
Cholesterol • Seen in Chloroform
• Colorless refrigerated Radiographic • Markedly high 10% NaOH
notched specimen (droplet dye specific gravity
plates form lipids) • Colorless when measured
• Nephrotic • Cholesterol by refractometer
syndrome crystal like

Cystine Cholesterol

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Bilirubin Radiographic dye

Abnormal Crystals seen in Acid/Neutral Urine

Abnormal Crystals seen in Acid/Neutral Urine
Crystal/Color Comments Solubility Appearance
Crystal/Color Comments Solubility Appearance
Leucine • Crystals Associated Hot alkali or
• Yellow-brown With Liver Disorders alcohol Sulfonamides • Seen in inadequate Acetone
• Varied (colorless to patient hydration
• Spheres • Presence should be
yellow-brown) • possibility of tubular
(concentric accompanied by • Needles, rhombics, damage if crystals are
circles and tyrosine crystals whetstones, sheaves forming in the
radial striations) of wheat, and nephron
Tyrosine • seen in conjunction Alkali or rosettes
• Colorless–yellow with leucine crystals in heat Ampicillin • Seen in massive doses Refrigera-
• Fine needle specimens with • Colorless of this penicillin tion forms
(clump or positive chemical test • needles (form compound without bundles
rosette form) results for bilirubin bundles following adequate hydration
• May be encountered refrigeration
in inherited disorders
of amino-acid
metabolism

Leucine Tyrosine

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Sulfonamide Ampicillin

Urinary Sediment Artifacts

Urinary Sediment Artifacts t
Artifact Comments Appearance
Starch Granule • From cornstarch
• Resemble fat used as glove
Contaminants from improper collection droplets when powder
polarized • Highly refractile
starch, oil droplets, air bubbles, pollen grains,
• Dimpled center sphere
fibers, and fecal contamination
Oil Droplets • highly refractile
often very highly refractile or occur in a different • From OIO and may
microscopic plane contamination resemble RBCs
Not necessarily to be reported
Air Bubbles
• occur when the
specimen is placed
under a cover slip

Urinary Sediment Artifacts

Artifact Comments Appearance
Pollen grains • spheres with a cell wall
• Concentric and occasional
circles concentric circles

Hair and fibers • mistaken for casts

from clothing
and diapers
• usually much longer
and more refractile END 
Fecal Artifacts • presence of a fistula
• variety of between the intestinal Post quiz
sizes and and urinary tracts
shapes • appear as plant and
meat fibers or as brown
amorphous material

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