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Urinalysis and its importance.pptx

  1. 1. TOPIC :
  2. 2. Urine formation  In the normal adults approx. 1200 ml of blood perfuses the kidney each minute .  That is 25% of the cardiac output .  The glomeruli receive blood through afferent arterioles and an ultrafiltrate of the plasma passes into the bowman’s space.  From there the filtrate is passed through the tubules and the collecting ducts.  Reabsorption and secretion of various substances .  Concentration of urine occurs .  180lt of glomerular filtrate in 24 hrs is reduced to 1- 2lt .
  3. 3.  Through the glomerular filtration and tubular secretion ,numerous waste products are eliminated from the body.
  4. 4. 1. General evaluation of health 2. Diagnosis of disease or disorders of the kidneys or urinary tract 3. Diagnosis of other systemic disease that affect kidney functions. ex plasma cell dyscrasias. 4. Monitoring of patients with diabetes 5. Screening for drug abuse both as a part of rehabilitation prog and in the world of professional sports. 6. To determine ovulation and pregnancy in women.
  5. 5. COMPOSITION OF NORMAL URINE IN ADULTS  VOLUME 600-2000ml  SPECIFIC GRAVITY 1.003-1.030  OSMOLALITY 300-900mOsm/kg  PH 4.6-8.0  GLUCOSE <0.5 gm  PROTEINS < 150 mg  UROBILINOGEN 0.5-0.04mg  CREATININE 14-26mg/kg (men)  11-20mg/kg  UREA NITROGEN 12-20gm  URIC ACID 250-750mg
  6. 6.  Sodium 40-220mEq  POTASSIUM 25-125mEq  CHLORIDE 110-250  Red cells , epithelial cells , WBCs - < 1-2 /HPF
  7. 7. SPECIMEN EVALUATION:  Before proceeding with any examination ,urine sample must be evaluated in terms of acceptability.  It includes-proper labeling -proper specimen for the reqs examination. -proper preservative -visible signs of contamination -transportation delay.
  9. 9. . For routine examination a clean glass or plastic container which should be dry, chemically clean, leak proof with a tight fitting stopper is used. 1st specimen voided in the morning is preferred. A MID – STREAM SAMPLE is required. 2. POST–PRANDIAL SPECIMEN is sometimes required for glucose estimation ,to monitor insulin therapy in diabetes mellitus. 3. 24- HOUR SPECIMEN: for quantitative estimation of proteins ,hormones.
  10. 10. COLLECTION METHODS 1.Midstream specimen: used for all types of examinations. First half of stream serves to flush out contaminating cells and microbes from urethra and perineum. subsequent stream is collected which is from the urinary bladder. 2.Clean-catch specimen : for bacteriologic culture. 3.Catheter specimen: in bed-ridden ,ill-patients with urinary tract obstruction. 4.Plastic bag tied around genitals : used in infants and incontinent adults.
  13. 13. PHYSICAL EXAMINATION 1. VOLUME : Normal average volume = 1.5 litre/day (600-2500ml/day) I . POLYURIA : Urinary volume > 2500mL  CAUSES : -Excessive intake of water ( polydipsia ). - Diabetes mellitus and diabetes insipidus. - Drugs with diuretic effect such as caffeine , alcohol and diuretics. -.chronic renal failure
  14. 14. 2. OLIGURIA :  Causes –  A. PRERENAL : loss of intravascular volume - haemorrhage - dehydration - severe vomiting -severe burns
  15. 15. B. POSTRENAL : bilateral hydronephrosis -long standing obstruction of urinary tract . Obstruction any where in the urinary tract : Clots , stones , strictures , tumour, sloughed tissuse C .RENAL PARENCHYMAL DISEASES:
  16. 16. III . COMPLETE SUPRESSION : Of urine < 150mL /day is called anuria. CAUSES : -Retention of urine as in BPH and stricture in urethra. -Stone and tumuors in kidney.
  17. 17. 2. COLOUR : Normal urine is clear , pale or straw colour due to urochrome pigment. Increases during - Fever -Thyrotoxicosis - Starvation Small amounts of urobilins and uroerythrin. ABNORMAL COLOURS : a. COLOURLESS – after ingestion of large amount of water, polyuria. b. DEEP AMBER – after exercise, high grade fever. c. DEEP YELLOW- Jaundice
  18. 18. d. ORANGE BROWN- excreted urobilinogen is colourless, but it is converted in presence of light and low pH to urobilin . e. RED/PINK – in heamoglobinuria , haematuria , myoglobinuria and porphyria. f. DARK BROWN/ BLACK- in rhabdomyolysis and alkaptonuria . g. GREEN- phenol poisoning h. MILKY- presence of chyle , fat.
  19. 19. 3. APPEARANCE :  Normal urine is clear  CAUSES OF TURBIDITY : -Crystals precipitation -Amorphous phosphate , ammonium -Urate , carbonate -Cellular elements leukocytes -Bacterial growth
  20. 20. 4. ODOUR (SMELL)  Normally urine -mild aromatic due to presence of urinoids.It may change to : a. FRUITY- Ketoacidosis , starvation b. MUSTY - Phenylketonuria c. FISHY – UTI with Proteus d. AMMONICAL - UTI with Escherichia coli e. FOUL- UTI f. SULFUROUS - Cystinuria
  21. 21. 5.SPECIFIC GRAVITY - It depends on amount of solutes in solution. -It reflects the relative degree of conc or dilution of a urine specimen. - It helps in evaluating the concentrating and diluting abilities of the kidneys - Urea( 20 %) ,Na Cl (25%), Sulphate , Phosphate – major contributors - SG ranges from 1.003-1.035. - Normal adults with adequate fluid intake 1.016 – 1.022
  22. 22.  INCREASE IN SG : Diabetes mellitus Nephrotic syndrome Fever Congestive heart failure  DECREASE :<1.007 - hyposthenuric Diabetes insipidus Compulsive water drinking Isothenuric –SG is fixed
  23. 23. 1. URINOMETRE METHOD: Based on the principle of buoyancy 2.REFRACTOMETER METHOD : measures the refractive index of the dissolved solids. 3.REAGENT STRIP METHOD : indirect method . 3 main ingredients : polyelectrolyte , indicator and a buffer.
  24. 24. pH: Normal reaction of urine is acidic with pH 4.6 to 7.6. CAUSES OF HIGHLY ACIDIC URINE : a. Protein-rich diet. b. UTI by E.coli c. Respiratory and metabolic acidosis d. Ingestion of acidic food. CAUSES OF ALKALINE URINE: a. If specimen is allowed to stand at room temperature , it becomes alkaline.
  25. 25. b. For the treatment of uric acid calculi c. UTI by urea splitting bacteria – proteus, pseudomonas 1.LITMUS PAPER TEST : 2. Ph INDICATOR PAPER : 3. PH METER : 4. REAGENTS STRIP TEST:
  26. 26. Litmus paper test of urine
  28. 28. PROTEINS : 150 mg of proteins is excreted in urine daily. Average urine protein concentration is 2-10 mg/dl. - Albumin - Globulin - Retinal BP - Immunoglobulin - Tamn-Horsfall Proteins
  29. 29. TYPES OF PROTEINURIA : a . GLOMERULAR - Proteinuria is due to increased permeability of glomerular capillary. Two types – selective and non selective Selective- in early stages of glomerular disease , there is increased excretion of lower molecular weight proteins. When larger moleculer weight proteins are excreted - non selective proteinuria. It indicates greater glomerular damage. Can cause heavy proteinuria > 3-4 gms /day.
  30. 30. b. TUBULAR :  Loss of small amount of urinary protein that would otherwise be largely reabsorbed.  These proteins are usually low molecular weight.  Seen in acute and chronic pyelonephritis , heavy metal poisoning, interstitial nephritis. C. OVERFLOW :  Overflow of excess levels of a protein in the circulation , occurs in urine.
  31. 31. d. POSTURAL :  Orthostatic or postural proteinuria occurs in 3-5% of apparantly healthy young adults.  seen at day time.  Not at night when recumbant position is assumed.  Persistent proteinuria may develop at a later date.  May result due to an exaggerated lordotic position or inferior vena caval compression between liver and vertebral column  Daily excretion of protein rarely exceeds 1gm.
  32. 32. e. MICROALBUMINURIA :  Presence of albumin above the normal level but below the detectable range.  20-250mg/ day  Earliest sign of renal damage in diabetes mellitus.  Detection of microalbuminuria : It cannot be detected by routine tests.  - Measurement of albumin –creatinine ratio in a random urine sample.  - Measurement of albumin in an early morning or random urine sample or in a 24 hr sample.  Exact quantitation – RIA and ELISA.
  33. 33. METHODS FOR PROTEIN DETECTION :  HEAT COAGULATION METHOD Principle – Proteins get precipitated when boiled in acidic solution. For testing urine should be just acidic , if not- acidify by adding few drops of 10% acetic acid.
  35. 35. SULPHOSALICYLIC ACID TEST  Addition of sulphosalicylic acid to the urine causes formation of a white ppt.  Proteins are denatured by organic acids and precipitate out.  More sensitive and reliable than boiling test. HELLER’S NITRIC ACID REAGENT STRIP METHOD  Bromophenol (indicator) coated readymade strips are used.
  36. 36.  This test is semi quantitative.  It is mainly reactive to albumin and false negative in the presence of Bence- Jones proteins , myoglobin, haemoglobin.  as protein carry a charge at physiologic ph , their presence will elicit a ph change .
  37. 37. Negative Trace + (30 mg/dL) ++ (100 mg/dL) +++ (300 mg/dL) ++++ (2000 mg/dL) Chemical Principle H H H H H H Pr Pr Pr Pr Pr Pr “Protein Error of Indicators Method” Pr Pr Pr Pr Pr Pr Tetrabromphenol Blue (buffered to pH 3.0) H+ H+ H+ H+ H+ H+ Read at 60 seconds RR: Negative
  38. 38. QUANTITATIVE ESTIMATION OF PROTEIN IN 24 HR URINE SAMPLE  Instrument used is Esbach’s albuminometer .  Esbach’s reagent –picric acid (10g), citric acid (20) in distilled water to make 1000 ml of solution.  Sample collection : begins at 8am in the morning and continued till 8 am nxt day.  A small volume {100-150 ml} called aliquot is collected.
  40. 40. BENCE –JONES PROTEINURIA These are monoclonal immunoglobulin light chains. Synthesized by neoplastic plasma cells. Excess production occurs in plasma cell dyscrasias like multiple myeloma and primary amyloidosis. When heated , they precipitate at temperatures between 40-60 celsius and precipitate disappears at 85-100 celsius. Osgood & Haskins method is used besides the heating test. These tests are now replaced by protein electrophoresis of concentrated urine sample.
  41. 41. GLUCOSE AND OTHER SUGARS IN URINE : Small amount present in fasting urine which is not detectable by chemical methods. Presence of chemically detectable glucose in urine – Glycosuria. It depends on -blood sugar level - rate of glomerular filtration - tubular reabsorption Normal renal threshold for glucose 180-200 mg/ dl. Diabetes mellitus – most common cause. Also seen in – hyperthyroidism - hyperpitutarism
  42. 42. Other causes – myocardial infarction - cerebral haemorrhage -brain tumours -uremia - severe liver ds Sometimes the sugar level is normal but glycosuria occurs due to decrease in renal threshold. Non pathological causes : -Pregnancy -Stress and anxiety -Alimentary glycosuria
  43. 43. METHODS : COPPER REDUCTION METHODS : BENEDICT’S QUALITATIVE TEST : Benedict’s reagent ( copper sulphate 17.3 gm sodium carbonate 100 gm sodium citrate 173 gm ) 5 ml benedict’s reagent + 8 drops of urine PRINCIPLE : Cu 2+ Cu+ in hot alkaline medium Cu + OH Cu OH 2 CuOH Cu2O (RED)
  44. 44. This is a Non specific test for glucose . Other carbohydrates - fructose - galactose - lactose - pentoses and non carbohydrates -ascorbic acid - salicylates - cephalosporins also reduce copper sulphate solution.
  45. 45.  Depending on the colour of the precipitate the sugar content is estimated  Green- 0.5%  Yellow – 1%  Orange -1.5%  Red- 2%  Brick red ->2%
  46. 46. REAGENT STRIP TEST It is specific for glucose. Based on glucose oxidase –peroxidase activity. Reagent strip is impregnated with the 2 enzymes and a chromogen. PRINCIPLE Glucose + O2 (room air) gluconic acid+ H2O2 H2O2 + chromogen peroxidase Oxidised chromogen (blue) + H20
  47. 47. FALSE POSITIVE TEST : Occurs - in the presence of strong oxidizing cleansing agent in the urine container. - in the low specific gravity. FALSE NEGETIVE TEST : Occurs - sodium Fluoride -used as a preservative. - ascorbic acid - glycolytic enzymes from cells and bacteria.
  48. 48. TOPIC :
  49. 49. KETONES : Inadequate carbohydrate in the diet or a defect in carbohydrate metabolism - body tends to metabolize increasing amount of fatty acids. This leads to increase in intermediate products like – Ketones appear in blood which are ultimately excreted in urine. Aceto acetic acid (20 %) , acetones ( 2%), 3-hydroxy butyrate (78 %)
  50. 50. CAUSES OF KETONURIA : Diabetic Ketonuria Ketonuria implies the presence of ketoacidosis. Upto 50 mg of aceto acetic acid per dl may be present without clinical evidence of ketosis. Type 1 diabetic patients are more prone to episodes of ketosis , associated with -infection -stress.
  51. 51. Non Diabetic Ketonuria In infants and children ketonuria occurs in conditions - acute febrile diseases - persistent vomiting or diarrhea Inherited metabolic disorders In hyperemesis of pregnancy In cachexia also seen following severe exercise Or with a low – carb diet for weight reduction
  52. 52. METHODS 1.ROTHERA’S TEST (CLASSIC NITROPRUSSIDE REACTION ) 5 ml urine + excess of (NH4)2SO4 (Saturate it ) Few crystals of sodium nitroprusside Slowly add 1-2 ml of liqour ammonia Purple ring at junction.
  53. 53.  The purple colour is given by acetone and acetoacetic acid.  B-hydroxybutyrate does not gives this test.  FALSE- POSITIVE TEST  can occur in the presence of L-dopa and in phenylketonuria.
  55. 55. 2.ACETEST TABLET TEST : This is Rothera’s test in the form of a tablet. The Acetest tablet consists of sodium nitroprusside , glycine , and an alkaline buffer. A purple lavender discoloration of the tablet indicates the presence of acetoacetate or acetone (>=5 mg/dl). The test is more sensitive than reagent strip test for ketones.
  56. 56. 3.FERRIC CHLORIDE TEST (Gerhardt s) : Addition of 10% ferric chloride solution drop by drop to urine causes solution to become reddish or purplish if acetoacetic acid is present. This test is given only by acetoacetic acid not by the other two substances. If considerable amount of phosphate are present a precipitate of ferric phosphate is produced. It is necessary to filter this off. The test is not specific since certain drugs (salicylate and L- dopa ) give similar reaction.
  57. 57.  These can be differentiated from acetoacetic acid by their different behaviour towards heat.  On thoroughly boiling the urine ,acetoacetic acid loses co2 and is converted into acetone, which no longer gives the test.  Salicylates are unaffected by boiling the urine and colour persists.
  58. 58.  Neither of these commonly used test is given by b- hydroxybutyrate .  To test for this compound it is necessary to oxidise it to acetoacetic acid.
  59. 59. BLOOD IN URINE  HAEMATURIA- presence of abnormal number of red cells in urine.  Causes- IgA nephropathy  -focal GS  - neoplasia  - trauma or calculi anywhere in the urinary tract  - bleeding disorder
  60. 60. HAEMOGLOBINUREA  Presence of free hb in urine.  Screening test for hb is a useful adjunct to the microscopic exam. Of the sediment .  Causes –intravascular haemolysis  extensive burns  prosthetic heart valves etc .  Free hb binds with haptoglobin ,once this binding capacity is saturated hb appears in urine.
  61. 61. REAGENT STRIP TEST FOR HAEME COMP.  Principle –O2 is liberated from peroxide in the strip by the peroxidase – like activity of haeme in free hb.  H2O2 +chromogen oxidised  chromogen +H2O  Color change is obtained.  Strip tests can detect 0.05-0.3 mg hb /dl urine.   BENZIDINE TEST : positive for haematuria, haemoglobinuria,myoglobinuria.
  62. 62. 10% benzidine solution in glacial acetic acid. 1ml of this solution + 1ml urine – test 1ml of benzidine sol. + 1 drop of blood – positive control H2O2 1ml is added to both tubes Appearance of bluish colour -positive for occult blood ORTHOTOLUDINE TEST: In the place of benzidine orthotoludine is used.it is more sensitive than benzidine test
  63. 63.  False positive:  Contamination of urine by menstrual blood in females.  Contamination by oxidizing agents, bleach etc.  False negative:  Presence of reducing agents like ascorbic acid in high concentration.  Use of formalin as a preservative for urine.
  64. 64. BILIRUBIN  Breakdown product of hb in the RE of the spleen , liver , bone marrow.  Bilirubin linked to albumin – unconjugated , insoluble in water.  In liver it is conjugated with glucuronic acid to form bilirubin glucuronide- water soluble .  Normal adult urine contains 0.02 mg/dl of bilirubin.
  65. 65. BILIRUBINURIA -CAUSES  Obstruction to bile outflow from the liver –intra or extrahepatic  Gallstones in CBD  CA head f pancreas  Hepatocellular disease –periportal inflammation , fibrosis .  Hepatotoxic drugs or toxins  Dubin –johnson and Rotor .  Bilirubinuria is associated with yellow – brown to greenish brown urine that may have a yellow foam .  - elevated serum bilirubin , pale colored stools.
  66. 66. 1. FOUCHET’S TEST :  5ml fresh urine +2.5 ml of 10% barium chloride.  Barium sulphate - bilirubin complex is ppted.  Filter to obtain the ppt on a filter paper.  To the ppt add 1 drop of fouchet’s reagent ( 25gms of trichloroacetic acid ,10 ml of 10% FeCl3 and DW 100ml ).  Immediate development of blue green colour.
  67. 67. 2. GMELIN’S TEST :  3ml conc HNO3 +equal quantity of urine .  Test tube is shaken gently ,play of colors is seen . 3. LUGOL IODINE TEST: 4. REAGENT STRIP TEST : based on the coupling reaction of bilirubin with a diazonium salt in acid medium . can detect 0.5 mg/dl bilirubin in urine . P-nitrobenzene diazonium p-toluene sulphonate is used.
  68. 68. UROBILINOGEN :  Normal output is0.5- 2.5 mg units /24 hrs .  These are colorless substances as compared to urobilins ,the oxidation products of urobilinogen that imparts yellow orange color to normal urine. 
  69. 69.  fresh urine sample should be used.  1. EHRLICH’S ALDEHYDE TEST :  Ehrlich’s reagent ( p-dimethylaminobenzaldehyde)  Reacts with urobilinogen to produce a pink color.  Intensity of the color depends on the amount of urobilinogen present.  Bilirubin should be removed first as it interferes with the reaction.  5 ml of fresh urine is taken in a test tube +0.5 ml of EHRLICH’S reagent is added. Allow to stand at room temperature for 5 minutes.
  70. 70.  both urobilinogen and porphobilinogen produce similar reaction , they can be differentiated by  WATSON –SCHWARTZ TEST .  1-2ml of chloroform is added and the test tube is shaken for 2 min and allowed to stand.  Pink colour in the chloroform layer ,pink coloration of aqueous portion indicates presence of porphobilinogen .
  71. 71.  FALSE NEGATIVE : can occur in the presence of  - urinary tract infection as nitrite oxidises urobilinogen to urobilin .  -antibiotic therapy
  72. 72. BILE SALTS  HAY’S TEST – Based on the fact that bile salts when present in the urine lower the surface tension.  Fresh clear urine sample is taken in a small beaker at room temperature .  A little dry ,finely powdered sulphur particles are added on the surface .  thymol used as a preservative may give false positive test.
  73. 73. INDIRECT TEST FOR UTI : It is not uncommon for significant UTI to be present in patients who do not experience typical symptomatology. If remain untreated , it can cause severe renal damage. So in high risk individual – elderly - pregnant - diabetic Two commonly utilized tests are : 1.) Reagent strip nitrite 2.) Leukocyte estarase
  74. 74. NITRITE  Many bacteria are able to reduce nitrate to nitrite and thus will generate a positive urine nitrite test when present in significant no.  E.coli, klebsiella, Enterobacter , Proteus, Staph. , Pseudomonas. REAGENT STRIP TEST: it is impregnated with p- arsanilic acid , which forms a diazonium salt when reacts with nitrite present in the urine.
  75. 75.  The compoud then reacts with benzoquinolone to form a pink azo dye.
  76. 76. LEUKOCYTE ESTERASE  Azurophilic granules of the human nuetrophils contain up to 10 proteins showing esterolytic activity which is commonly used as marker for these cells.  Leukocyte esterase activity can be indicative of remnants of cells that are not visible microscopically.  Positive leukocyte esterase results correlate with ‘significant’ numbers of neutrophils of fresh urine as a cut off point.
  77. 77. METHODS :  Neutrophilic esterases catalyze the hydrolysis of esters to produce their respective alcohols and acids.  It utilizes 3-hydroxy-5-phenyl-pyyrole-N-tosyl-L- alanine as a substrate , which reacts in the presence of leukocyte esterase to form pyrrole alcohol.  The alcohol then reacts with a diazonium salt to produce a purple color.  The intensity of the color produced is proportional to the amount of enzyme present, which is related to the number of neutrophils present.
  78. 78.  Oxidizing agents and formalin may give false – positive colors.
  79. 79. MICROSCOPIC URINALYSIS Microscopic urinalysis serves as a rapid confirmatory test for the presence of leukocytes and bacteria. Culture remains the Gold standard.
  80. 80. CELLS ERYTHROCYTES :  Under high power, unstained erythrocytes (RBCs) appear as pale biconcave disks that may vary somewhat in size but are usually about 7micron in diameter.  If the specimen is not fresh when it is examined, erythrocytes may appearas faint, colorless circles or shadow cells because the haemoglobin may dissolve out.
  81. 81.  They may become crenated in hypertonic urine and appear as small, rough cells with crinkled edges.  In dillute urine, the cells will swell and rapidly lyse, releasing haemoglobin and leaving only empty cell membranes referred to as ghost cells.  On occasion, erythrocytes may be confused with oil droplets or yeast cells.  Erythrocytes are found in small numbers (0-2 cells/hpf) in normal urine, more then 3 cells/hpf is considered abnormal.
  82. 82.  These include :- 1.) renal disease – glomerulonephritis 2.) lower urinary tract disease – calculus tumor 3.) extrarenal disease – accute appendicitis 4.) toxic reactions due to drugs 5.) physiologic causes , including exercise.
  83. 83. DYSMORPHIC ERYTHROCYTES : Red blood cells with cellular protusions or fragmentation are termed dysmorphic. Their presence in urine samples is strongly suggestive of renal glomerular bleeding. The so-called ‘G1 cell’ , which has a doughnut shape with one or more membrane blebs, may be more specific than dysmorphic cells for diagnosing glomerular hematuria.
  84. 84. LEUKOCYTES  NEUTROPHILS : - The polymorphonuclear leukocyte (neutrophil) is the predominant type of leukocyte (white blood cell [WBC] ) that appear in the urine. - When cellular degeneration has begun , nuclear detail may be lost, and neutrophils may then become difficult to distinguish from renal tubular epithelial cells. - In dilute or hypotonic urine , neutrophils swell and their cytoplasmic granules exihibit brownian movement. Because of the refractility of the moving granules, neutrophils in this setting are known as
  85. 85. ‘glitter’ cells. - The leukocytes esterase reagent strip is valuable in the confirmation of pyuria in hypotonic urine specimen. - Urinary neutrophil counts greater than 30 cells/hpf suggest acute infection, and repeated sterile cultures in this setting may indicate tuberculosis or a nephritis. - It is a reliable indicator of urinary tract infection.
  86. 86. EPITHELIAL CELLS  SQAMOUS EPITHELIAL CELLS : - These cells are the most frequent epithelial cell seen in normal urine, and likewise the least significant. - The distal one third of the urethra is lined by sqamous epithelial cells, and in the urine these cells are large and flat, with abundant cytoplasm and small round central nuclei. - Their margins are often folded.
  87. 87. TRANSITIONAL (Urothelial) EPITHELIAL CELLS : - Transitional epithelial cells line the urinary tract from the renal pelvis to the lower third of the urethra. - These cells are smaller than squamous cells , their size ranging from 40-200 micro m. - They are round or pear shaped , with a round centrally located nucleus. - The exception is the presence of large clumps or sheets of transitional cells in the absence of instrumentation (i.e catheterization).
  88. 88. RENAL TUBULAR EPITHELIAL CELLS : - These are the most significant types of epithelial cells found in urine because the finding of an increased number indicates tubular damage. - The Papanicolaou stain has been shown to be especially useful in distinguishing renal tubular cells from other mononuclear cells in urine. - Renal epithelial cells from the proximal and distal convoluted tubules occur singly and are large ( 14- 60micro m ) and coarsely granular eosinophilic cytoplasm.
  89. 89. PIGMENT IN RENAL TUBULAR EPITHELIAL CELLS - With hemoglobinuria or myoglobinuria, heme pigment is absorbed into the cells and converted to hemosiderin. - The cytoplasmic granules appear yellow- brown and stain for iron with Prussian blue. - Melanin granules are absorbed into the tubular cells in rare cases of melanuria.
  90. 90. CASTS :  Casts are the only formed elements of urine that have the kidney as their sole site of origin.  Tamm-Horsfall protein is the glycoprotein secreted by the thick part of the ascending loop of henle which constitutes about one third of the total urinary protein in normal individuals.  Tamm-Horsfall protein forms the matrix of all casts.  The protein forms a meshwork of fibrils that can potentially trap any elements present in the tubular filtrate including cells, cell fragments or granular material.
  91. 91.  Casts may be short and stubby or long and convoluted.  Casts typically have parallel sides and blunt ends, but with age they may begin to disintegrate and show thinning and irregularities.  Fibrils may separate , causing a frayed appearance .  Tails and tapering ends can be seen, and these disintegrating forms are referred to as cylindroids.  In the normal person , very few casts are seen in the urinary sediments. In kidney diseases , they may appear in large numbers and in many forms.
  92. 92.  Large numbers of casts may also be seen in healthy persons after strenuous exercise accompanied by proteinuria.  Casts formation increases with lower pH, increased ionic concentration, and when there is stasis or obstruction of the nephron by cells or cell debris.  It is also increased when larger than normal amounts of plasma proteins enter the tubules.
  93. 93. CLASSIFICATION OF CASTS :  CAST MATRIX 1.) HYALINE CASTS : Increased numbers are seen with renal diseases and transiently with exercise, heat exposure, dehydration, fever, congestive heart failure, and diuretic therapy. 2.) WAXY CASTS : They are easily visualized. Waxy casts are homogeneously smooth in appearance with sharp margins, blunted ends, and cracks or convolutions frequently seen along the lateral margins.
  94. 94. Hyaline casts
  95. 95. Waxy casts
  96. 96.  CELLULAR CASTS 3.) ERYTHROCYTE (RED BLOOD CELL) CASTS : - They are an indication of bleeding within the nephron. Glomerular damage allows erythrocytes to escape into the tubule. - Acute glomerulonephritides, lgA nephropathy, lupus nephritis, subacute bacterial endocarditis, and renal infarction.
  97. 97. RBC casts
  98. 98. 4.) LEUKOCYTE (WHITE BLOOD CELL) CASTS : - White blood cell casts are refractile, exhibit granules, and frequently multilobated nuclei will be visible unless disintegration has begun. - They are also seen with interstitial nephritis, lupus nephritis. 5.) RENAL TUBULAR EPITHELIAL CELL CASTS : - Renal tubular epithelial cell casts are seen in urine with acute tubular necrosis, viral disease (e.g, cytomegalovirus disease). 6.) MIXED CELLULAR CASTS :
  99. 99. Epithelial casts
  100. 100.  INCLUSION CASTS 7.) GRANULAR CASTS : Granular casts are fairly common and may appear in both pathologic and non pathologic conditions. - Granules may be small or large, and may originate from plasma protein aggregates that pass into the tubules from damaged glomeruli, as well as from cells. - These are seen in glomerular and tubular diseases, renal allograft rejection, viral infection and chronic lead poisoning.
  101. 101. Granular casts
  102. 102. 8.) FATTY CASTS : - Fatty material is incorporated into the cast matrix from lipid – laden renal tubular cells – nephrotic syndrome. 9.) CRYSTAL CASTS : - These casts indicate deposition of crystals in the tubule or collecting duct.  PIGMENTED CASTS 10.) HEMOGLOBIN (BLOOD) CASTS : - Most often hemoglobin casts , also known as blood casts are seen with erythrocyte casts and glomerular disease.
  103. 103. 11.) HEMOSIDERIN CASTS : - Hemosiderin granules in casts derive from pigment – laden renal tubular cells. 12.) MYOGLOBIN CASTS : - These casts are red- brown in color and occur with myoglobinuria following acute muscle damage. - These may be associated with acute renal failure. 13.) BILIRUBIN AND OTHER DRUG CASTS : - Bilirubin is seen in urine when there is obstructive jaundice and will color casts a deep yellow brown.
  104. 104. BROAD CASTS Broad casts are defined as those with a diameter two to six times that of normal casts. They indicate tubular dilation and / or stasis in the distal collecting duct. All types of casts may occur in broad forms and they are typically seen in individuals with chronic renal failure. They portend a poor prognosis.
  105. 105. CRYSTALS Crystals form by the precipitation of urinary salts when alteration in multiple factors affect their solubilities. These include changes in pH, temperature and concentration. The precipitation can appear in the urine in the form of either true crystals or amorphous material. The majority of crystal formation takes place in refrigerated specimens and those allowed to sit at room temperature for several hours. Knowledge of urine pH is a valuable aid in crystal identification because it is the pH that determines which chemical will precipitate.
  106. 106. CRYSTALS FOUND IN NORMALACID URINE  AMORPHOUS URATES (Calcium, Magnesium, Sodium, and Potassium Urates) Amorphous urates will precipitate upon standing in concentrated urine of a slightly acid pH. When large amounts are present , the urine sediment may appear pink- orange to reddish brown on macroscopic examination; this appearance has been referred to as ‘brick dust’. Microscopically this amorphous material appears as yellow –brown small granules that can form clumps and adhere to fibers and mucous threads.
  107. 107.  CRYSTALLINE URATES (Sodium, Potassium, and Ammonium) Both amorphous urates and crystalline forms will slowly revert to uric acid plates on acidification with acetic acid.  CRYSTALLINE URIC ACID Uric acid crystals occur at low pH(5-5.5) and seen in a variety of shapes including rhombic or four-sided flat plates, prisms, oval forms with pointed ends, wedges. The majority are colored typically yellow or reddish brown.
  108. 108. Uric acid crystals
  109. 109. Large numbers of uric acid crystals and urates may reflect increased nucleoprotein turnover, chemotherapy of leukemias or lymphoma, Lesch- Nyhan syndrome. They may also herald the urate nephropathy of gout.  CALCIUM OXALATES Dihydrates may appear at pH 6 or in neutral urine. Their classic form is that of a small, colorless, octahedron that resembles an envelope. Dumbbell shapes and ovoid forms may occur. Oxalate crystals in large numbers may reflect severe chronic renal disease.
  110. 110. Calcium oxalate crystals
  111. 111. Oxalate crystals
  112. 112. CRYSTALS FOUND IN NORMALALKALINE URINE  AMORPHOUS PHOSPHATES (Calcium and Magnesium) Like amorphous urates, amorphous phosphates have a granular appearance colorless and will produce a fine or lacy white precipitate macroscopically.
  113. 113.  CRYSTALLINE PHOSPHATES Triple phosphate (ammonium magnesium phosphate) crystals are one of the most easily identified urine crystal, although they commonly show a variation in size. They are colorless, three-to six –sided prisms with oblique ends referred to as coffin lids. They may form colorless sheets or flakes.  CALCIUM CARBONATE These uncommon crystals are small and colorless , with dumbell or spherical shapes. They are distinguished from other production of carbon dioxide in the presence of acetic acid.
  114. 114. Triple phosphates crystals
  115. 115. CRYSTALS FOUND IN ABNORMAL URINE  CYSTINE Cystine crystals are colorless, refractile, hexagonal plates which appear in acid urine. They are soluble in water at pH less than 2 or greater than 8. TYROSINE In acidic urine, tyrosine forms fine silky needles that may be arranged in clumps . These are occasionally seen in the urine of patients with severe liver disease.
  116. 116. Cysteine crystals
  117. 117. Leucine crystals.