Urinalysis and Urine Microscopy

Gilbert Sterling O. 2014

 Specimen Collection & Handling
• A clean-catch midstream sample is preferred.
• If this is not feasible, bladder catheterization is
appropriate in adults; the risk of contracting a
urinary tract infection after a single
catheterization is negligible.
• Suprapubic aspiration is used in infants.
 Specimen Collection & Handling
• Urine is best examined when fresh, but a brief
period of refrigeration is acceptable
• Bacteria multiply at room temperature 
unrefrigerated sample is unacceptable
• High urine osmolality and low pH favor
cellular preservation  typically of particular
value in suspected GN
 Appearance
• Normal urine is clear with a faint yellow tinge
because of the presence of urochromes.
• As the urine becomes more concentrated, its
color deepens.
• Bilirubin, other pathologic metabolites, and a
variety of drugs may discolor the urine or
change its smell.
• Suspended erythrocytes, leukocytes, or
crystals may render the urine turbid.
Appearance
Appearance
 Specific Gravity
• The specific gravity of a fluid is the ratio of its weight to
the weight of an equal volume of distilled water.
• Specific gravities of 1.001 to 1.035 correspond to an
osmolality range of 50 to 1000 mOsm/kg.
• A specific gravity near 1.010 connotes isosthenuria,
with a urine osmolality matching that of plasma.
• Relative to osmolality, the specific gravity is elevated
when dense solutes such as protein, glucose, or
radiographic contrast agents are present.
 Specific Gravity
Can be measured by:
1) Hydrometer
2) Well-characterized relationship between
urine specific gravity and refractive index
3) Dipstick
 Specific Gravity
• The specific gravity is used to determine whether the
urine is or can be concentrated.
• During a solute diuresis accompanying hyperglycemia,
diuretic therapy, or relief of obstruction, the urine is
isosthenuric.
• In contrast, with a water diuresis caused by
overhydration or diabetes insipidus, the specific gravity
is typically 1.004 or lower.
• In the absence of proteinuria, glycosuria, or iodinated
contrast administration, a specific gravity of more than
1.018 implies preserved concentrating ability.
 Specific Gravity
• Measurement of specific gravity is useful in
differentiating between prerenal azotemia and
acute tubular necrosis (ATN), and in assessing
the significance of proteinuria observed in a
random voided urine sample.
Routine Dipstick Methodology
 pH
• The physiologic urine pH ranges from 4.5 to 8.
• The determination is most accurate if performed
promptly, because growth of urea-splitting
bacteria and loss of carbon dioxide raise the pH.
• In addition, bacterial metabolism of glucose may
produce organic acids that lower pH.
• These strips are not sufficiently accurate to be
used for the diagnosis of renal tubular acidosis.
 Protein
• The protein reaction may be score from trace
to 4+, or by concentration. Their equivalence
is as follows: trace, 5 to 20 mg/dl; 1+, 30
mg/dl; 2+, 100 mg/dl; 3+, 300 mg/dl; 4+,
greater than 2000 mg/dl.
• Highly alkaline urine, especially after
contamination with quaternary ammonium
skin cleansers, may produce false-positive
reactions.
 Protein
• Protein strips are highly sensitive to albumin
but less so to globulins, hemoglobin, or light
chains. If light-chain proteinuria is suspected,
more sensitive assays should be used.
• Urine that is negative by dipstick but positive
by sulfosalicylic acid precipitation is highly
suspicious for light chains
 Protein
• If the urine is very concentrated, the presence
of a modest protein reaction is less likely to
correspond to significant proteinuria in a 24-
hour collection or when assessed by spot
urine protein:creatinine ratio
 Tests of Urinary Protein Excretion
• Tests can be done by using sulfosalicylic acid
test, spot protein-to-creatinine ratio or 24-
hour urine collection
• 24-hour urine collection for protein and
creatinine is considered the gold standard
measure of urine protein excretion
 Blood
• False-positive reactions occur if the urine is
contaminated with other oxidants such as
povidone-iodine, hypochlorite, or bacterial
peroxidase.
• Ascorbate yields false-negative results.
• Myoglobin is also detected, because it has
intrinsic peroxidase activity
 Blood
• A urine sample that is positive for blood by
dipstick analysis, but shows no red cells on
microscopic examination, is suspect for
myoglobinuria or hemoglobinuria
• Pink discoloration of serum may occur with
hemolysis, but free myoglobin is seldom
present in a concentration sufficient to change
the color of plasma
 Glucose
• High concentrations of ascorbate or ketoacids
reduce test sensitivity.
• However, the degree of glycosuria occurring in
diabetic ketoacidosis is sufficient to prevent
false-negative results despite ketonuria
 Ketones
• Some strips can also detect acetone, but none
react with β-hydroxybutyrate. False-positive
results may occur in patients who are taking
levodopa or drugs such as captopril or mesna
that contain free sulfhydryl groups
 Urobilinogen
• Urobilinogen is a colorless pigment that is
produced in the gut from the metabolism of
bilirubin
• In obstructive jaundice, bilirubin does not reach
the bowel, and urinary excretion of urobilinogen
is diminished
• Other forms of jaundice  increased
• Sulfonamides may produce false-positive results,
and degradation of urobilinogen to urobilin may
yield false-negative results
 Bilirubin
• Conjugated bilirubin is not normally present in
the urine.
• False-positive results may be observed in
patients receiving chlorpromazine or
phenazopyridine.
• False-negative results occur in the presence of
ascorbate
 Nitrite
• The nitrite screening test for bacteriuria relies on
the ability of gram-negative bacteria to convert
urinary nitrate to nitrite, which activates a
chromogen.
• False-negative results occur with infection with
enterococcus or other organisms that do not
produce nitrite, when ascorbate is present, or
when urine has not been retained in the bladder
long enough (approximately 4 hours) to permit
sufficient production of nitrite from nitrate.
 Leukocytes
• The test threshold is 5 to 15 white blood cells
per high-power field (WBCs/HPF).
• False-negative results occur with glycosuria,
high specific gravity, cephalexin or tetracycline
therapy, or excessive oxalate excretion.
• Contamination with vaginal material may yield
a positive test result without true urinary tract
infection
 Microalbumin Dipsticks
(Microalbuminuria)
• Albumin-selective dipsticks are available for
screening microalbuminuria in patients with
incipient diabetic nephropathy.
• The most accurate screening occurs when first
morning specimens are examined, because
exercise can increase albumin excretion.
• Normally, the urine albumin concentration is
less than the 20 mcg/L detection threshold for
these strips
 Cellular Elements
• RBC
• WBC
• Epithelial cells
• Cells from bladder, vaginal sq. cells (if
contaminated)
• Less common  tumor from uroepithelium,
lymphoma or leukemic cells
• Others
Monomorphic Red Blood Cells
• Microscopic hematuria  ≥2 RBC per HPF on 2 separate
urine exams (Lange)
• Monomorphic (round and uniform)  extrarenal bleeding
Dysmorphic Red Blood Cells
• Dysmorphic RBC (blebbing, budding and partial loss of cellular membrane)
 renal lesion, most often glomerular process
• Acanthocytes  1 form of dysmorphic RBC that have a ring form with
vesicle-shaped protrusions  results in smaller size and shape
White Blood Cells
• WBC in urine  pyuria; white cells have a multilobed nucleus and a
granular cytoplasm; Up to 5 WBC/HPF is considered normal
• Neutrophils are the most common WBC
• Eosinophil  AIN, cholesterol emboli, GN, UTI, prostatitis
• Lymphocytes  Chronic tubulointerstitial dz (Sarcoidosis)
Epithelial Cells
• Only renal tubular epithelial cells have clinical relevance  diagnostic of
ischemic or nephrotoxic ATN but seen with glomerular disease.
• Lipid-filled tubular epithelial cells & free fat droplets  high-grade
proteinuria
Malignant Cells
• Atypical lymphocytes or lymphoid cells  lymphoma of kidney or
bladder
• Leukemic cells  infiltration of the kidneys or GU tract
Decoy Cells
• Present in someone infected by BK-polyomavirus treated with
tacrolimus or mycophenolate mofetil (MMF); these cells are renal
tubular epithelial cells and other uroepithelial cells associated with
viral infection
• They have ground-glass nucleus
Budding Yeast
• Other cellular elements that can be seen  bacteria (UTI)
• Other organisms  C. albicans, M. Tb, Cryptococcus & S. hematobium
• Budding yeasts are usually found with WBC, RBC, abnormal epithelial
cells and cellular casts
Squamous Epithelial Cells
Comes from urethral, vaginal or cutaneous origin  large, flat cells with
small nuclei
Transitional Epithelial Cells
• They lie the renal pelvis, ureter, bladder and proximal urethra.
• In hypotonic urine, they may be confused with swollen tubular
epithelial cells.
Fat Droplets
More variable in shape compared to RBC, slightly greenish-tinged, have a
darker edge and are more globular
 Urinary Casts
• Formed within and only in DCT or collecting
tubule  hence the shape conforms to the
lumens
• Typically cylindrical with regular margins but
can be fractured during the processing
• All casts have an organic matrix composed of
Tamm-Horsfall mucoprotein that is
synthesized and released at the loop of Henle
 Urinary Casts
Even with glomerular injury causing increased
glomerular permeability to plasma proteins
resulting in proteinuria, most matrix or “glue”
the cements urinary casts together is Tamm-
Horsfall mucoprotein, although albumin and
globulin are also incorporated
Hyaline Casts
• Refractile cast and not associated with any particular disease
• May be found as high as 5-10 per HPF
• Found in small volumes of concentrated urine and after diuretic therapy
Red Blood Cell Casts
• Even 1 RBC cast is significant for GN or vasculitis
• Often found with free dysmorphic RBC
• These casts typically contain red cells with a hyaline or granular cast
White Blood Cell Casts
• Most commonly found in acute pyelonephritis or tubulointerstitial disease
patient
• Other (inflammatory) disease  glomerular disorder, cholesterol emboli
• Often found with free white cells ; + neutrophil  pyelonephritis; +
eosinophils  AIN
Epithelial Cell Casts
• Injury to tubular epithelium + necrosis  shedding of cells into lumen
• Although desquamation of these cells is most indicative of tubular
injury from either ischemia or nephrotoxins, they are also seen in GN
& vasculitis
Granular Casts
• Composed of degenerating cells and reflect tubular injury
• Most often seen in ATN from degenerating tubular epithelial cells,
can also be degraded RBC or WBC
Waxy Casts
• As granular casts continue to degenerate, they form waxy casts
• Relatively slow process  suggest advanced kidney disease, either
subacute in the setting of AKI or in CKD
Broad Casts
• Wider than other casts and are thought to form in the large (dilated)
tubules of nephrons with sluggish urine flow
• Indicative of advanced kidney disease
Fatty Casts
• Tubular epithelial cells filled with lipid droplets, known as oval fat
bodies and those contained in a cast matrix constitute fatty casts
• Found in significant level of proteinuria and lipiduria  nephrotic
syndrome
• Composed of cholesterol and cholesterol esters
Oval Fat Bodies
• Seen in nephrotic syndrome
• Patof: Lipiduria  tubular cells reabsorb luminal fat  sloughed
tubular cells contain fat droplets called oval fat bodies
 Urine Crystals
Formation of crystals most importantly
depend on:
• Degree of supersaturation of constituent
molecules
• Presence/absence of inhibitors of
crystallization
• Urine pH
May form in normal subjects or in patients
with crystaluria
Urine Crystals
Urine Crystals
 Uric Acid Crystals
• Acid urine favors the conversion of relatively soluble urate salts into insoluble uric acid
• Cause asymptomatic crystalluria, renal failure from crystal-induced tubular obstruction or frank nephrolithiasis
• In tumor lysis syndrome, it can cause severe uric acid crystalluria and AKI
• Low urine volumes also contribute to the formation of uric acid crystals and stone formation
• Rhomboid or rosette shaped
Uric Acid Crystals
Can also be needle shaped
 Calcium Oxalate Crystals
• Independent of urine pH
• Excess urinary oxalate  seen in ethylene glycol ingestion and SBS, associated with calcium oxalate crystal excretion and
nephrolithiasis
• Hypocitraturia  important factor
• Envelope shaped if dihydrate, dumbbell shaped if monohydrate
• Also seen within cast matrix and repesent acute oxalate nephropathy from enteric hyperoxaluria or primary hyperoxaluria
type 1 and 2
Cystine Crystals
• Seen in patients with hereditary disorder known as cystinuria
• Tend to precipitate when their concentration exceeds 300 mg/L of urine
• Acid urine (pH <7)also increases crystallization; they are hexagonal in shape
 Magnesium Ammonium Phosphate Crystals (Triple
Phosphate Crystals) or (Struvite)
• Struvite or “infection stones” are made up of magnesium ammonium phosphate and
calcium carbonate-apatite
• Normal urine is undersaturated with ammonium phosphate, however, infection with
certain bacteria increase the ammonium concentration and hence the pH (>7)
• Coffin lid crystal
Amorphous Crystals
• If phosphate, pH is ≥7, if urates, pH is ≤7
• Small, irregularly shaped crystals
• Can be of different compositions (urates, xanthines, phosphate)
depending on pH
Bilirubin
• Acidic pH <7
• Small needle-like to granular yellow or yellow-brown crystals
• Indicates bilirubinuria due to conjugated bilirubin
Calcium Phosphate
• Colorless
• Blunt-ended needles or prisms, often in rosettes, can be amorphous
 Drug-Associated Crystals
• Acyclovir
• MTX
• Sulfadiazine
• Triamterene
• Vitamin C
• Indinavir
 Characteristic Urine Sediments
Acute Nephritic Syndrome

• Urine may be pink or pale brown and turbid

• Blood and moderate proteinuria  dipstick
• Dysmorphic RBC and RBC casts
• Granular and hyaline casts
• WBC casts  rare
 Characteristic Urine Sediments
Nephrotic Syndrome

• Urine is clear or yellow

• Foaminess  elevated protein content altering
the urine surface tension
• Sediment is bland
• Hyaline casts and lipiduria with oval fat bodies or
lipid-laden casts predominate
• Granular casts and a few tubular cells
• A few RBCs
 Characteristic Urine Sediments
Chronic Glomerulonephritis

• “Telescoped” sediment  presence of the

elements of a nephritic sediment together
with broad or waxy casts (indicative of tubular
atrophy)
• Dipstick  heavy proteinuria
 Characteristic Urine Sediments
Acute Tubular Necrosis

• Tubular cells
• Tubular cell casts
• Muddy brown granular casts
 Characteristic Urine Sediments
Pyelonephritis

• WBC casts and innumerable WBCs along with

bacteria

Lower Tract Infections

• WBC casts are absent

 Sources
• Nephrology in 30 days; 2nd edition
• National Kidney Foundation’s, Primer on
Kidney Diseases
• Dr Har’s Practicum Guide