Microscopic examination of urine

Microscopic examination of urine

1. MICROSCOPIC EXAMINATION OF URINE SUNIL KUMAR.P Haematology& Transfusion medicine 12/19/2017 1 SUNIL KUMAR.P

2. Microscopic examination of urinary deposit or sediment is an essential part of urine examination. The deposits are divided into two main groups. 1. Organized deposits ( organic) 2. Un organized deposits ( In organic) 12/19/2017 2 SUNIL KUMAR.P

3. Normal Reference ranges for Cells and casts 12/19/2017 3 SUNIL KUMAR.P

4. PROCEDURE 1. Centrifuge 10 mL of urine in a graduated conical centrifuge tube and centrifuge at a speed of 1500 – 2000 RPM for 5 min. 2. The supernatant is poured off. 3. Resuspend the sediment in 1 mL of urine. 4.Take a small drop of the suspended urine on a glass slide 5. mount with a cover slip and examine under the microscope. 12/19/2017 4 SUNIL KUMAR.P

5. ORGANIC DEPOSITS Organic deposit consist of 1. Cells – a. Red blood cells b. White Blood Cells C. Epithelial cells 2. Casts – ( with or without inclusions) 3. crystals 4.Other abnormal cells or formed elements 12/19/2017 5 SUNIL KUMAR.P

6. Cells : They are expressed as number of cells per low power or high power field. 12/19/2017 6 SUNIL KUMAR.P

7. Red Blood Cells Presence of RBC’s > 2 /hpf in the urine indicates bleeding at any point in the urinary system from the glomerulus to the urethra. In glomerular diseases , the urine show red cell with cellular protrusions or fragmentation and are named as dysmorphic RBC’s. Causes : Hematuria 12/19/2017 7 SUNIL KUMAR.P

8. White Blood Cells ( WBC’s) Pus Cells Increased number of WBC’s ( mainly neutrophils > 5 / hpf) in urine is known as pyuria. It is indicative of urinary tract infections. Causes of Pus cells In urine ( Pyuria) (a). Pyelonephritis (b). Urethritis (c) . UTI 12/19/2017 8 SUNIL KUMAR.P

9. Epithelial Cells These are derived from the urinary tract (Transitional & renal) or genital tract (Squamous). A few ( 0-2/hpf) transitional cells from the bladder may be present in the normal urine and Squamous cells from the vulva and vagina usually contaminate a routine specimen from women. 12/19/2017 9 SUNIL KUMAR.P

10. CASTS 12/19/2017 10 SUNIL KUMAR.P

11. CASTS They are one of the organized elements which are formed only in the kidney and are indicative of renal disease. They are formed by solidification of Tamm Horsfall protein, a glycoprotein secreted in the distal convoluted tubules and collecting tubules. 12/19/2017 11 SUNIL KUMAR.P

12. Casts are cylindrical structures with parallel sides and rounded ends. They vary in size, shape and appearance. Cylindroids probably represents abortive casts. 12/19/2017 12 SUNIL KUMAR.P

13. The casts may have only proteins – hyaline Casts and Waxy casts. Trapped Granular Debris – Granular casts Epithelia cells – Epithelial casts Leukocytes – Leukocyte casts Red blood cells – RBC casts Fat Droplets – Fatty Casts 12/19/2017 13 SUNIL KUMAR.P

14. WBC’s Casts 12/19/2017 14 SUNIL KUMAR.P

15. Red Cells Casts 12/19/2017 15 SUNIL KUMAR.P

16. Epithelial Cells casts 12/19/2017 16 SUNIL KUMAR.P

17. Waxy casts 12/19/2017 17 SUNIL KUMAR.P

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19. CRYSTALS 12/19/2017 19 SUNIL KUMAR.P

20. These are not usually present in urine. Crystals of oxalates, urates and cystine are present in patients with history of renal stone. While urates alone present in gout. 12/19/2017 20 SUNIL KUMAR.P

21. Crystals Found in urine Crystal found in acidic urine 1. Amorphous urates 2.Crystalline urates 3.Crytalline uric acid 4.Calcium oxalate Crystal found in alkaline urine 1.Amorphous phosphates 2.Crystalline phosphates –triple phosphates 3.Calcium carbonate 4.Ammonium biurate crystals 12/19/2017 SUNIL KUMAR.P 21

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23. Uric acid crystals and urates Not found when urine is freshly passed, tend to develops when the urine has been standing. Amorphous urates appear as reddish granules and are dissolved by heating and by addition of sodium hydroxide, not by acetic acid. Uric acid crystals vary in shape and are usually stained a yellowish color , UA Crystals not dissolved by heat, acetic acid, or Hcl , but soluble when heated with NaOH . Shape- rhomboids, wedge shaped, hexagonal. 12/19/2017 23 SUNIL KUMAR.P

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25. Calcium oxalate Commanly found when the diet includes lots of tomatoes, spinach etc.., Typical envelope shape, and dumb bells, refractile , octahedral. insoluble in strong Hcl . Tendancy to clump together, may form stones. 12/19/2017 25 SUNIL KUMAR.P

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27. Hippuric acid crystals Enlongated prisms or plates. Yellow brown or colorless , soluble in water. Rarely seen. No clinical significance. 12/19/2017 27 SUNIL KUMAR.P

28. Leucine and tyrosine crystals. Usually occur together, found in condition associated with sever liver damage. Leucine crystals, appear as slightly yellow, oily looking spheres with radial and concentric striations. Not soluble in Hcl or ether. Tyrosine crystals : appear in the forms of very fine needles arranged in sheaves or clumps, colourless or yellow Soluble in ammonia and Hcl , insoluble in alcohol or ether. 12/19/2017 28 SUNIL KUMAR.P

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30. Crystal found in alkaline urine 1.Amorphous phosphates 2.Crystalline phosphates –triple phosphates 3.Calcium carbonate 4.Ammonium biurate crystals 12/19/2017 30 SUNIL KUMAR.P

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32. Crystals found in alkaline urine Ammonium magnesium phosphate( triple phosphate crystals). colourless, appear as coffin lid or as feathery or leaf like forms. prismatic(3-6 sided) In freshly passed urine they may indicate the presence of stones in the kidney or bladder. Phosphate may occur as an amorphous deposit in alkaline urine and are soluble in acetic acid. 12/19/2017 32 SUNIL KUMAR.P

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34. Dicalcium phosphates Appear in neutral or slightly acid urine as well as alkaline urine are colourless prisms arranged in stars or rosettes Because of the shape of the crystals, also called as stellar phosphates. The individual prisms are usually slender with one bevelled, wedge like end, sometimes needle like. Sometime found as large, thin irregular, usually granular plates. Soluble in acetic acid. 12/19/2017 34 SUNIL KUMAR.P

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36. Calcium carbonate Sometime mixed with the phosphate deposite , usually as amorphous granules, or more rarely, as colourless spheres and dumbells , Soluble in acetic acid with gas formation. 12/19/2017 36 SUNIL KUMAR.P

37. Ammonium biurate Found along with phosphate in decomposing when free ammonium is present. Appear as opaque, yellow crystals in the form of spheres, often covered with fine or coarse spicules . ‘Thorn apple.’ 12/19/2017 37 SUNIL KUMAR.P

38. Cholesterol crystals Rare Colourless Appear as flat plate with corner notch. Soluble in chloroform, ether, and hot alcohol. 12/19/2017 38 SUNIL KUMAR.P

39. Organic sediment Much more important than inorganic The organic structures are: tubular cast, granular cast, hyaline cast, waxy cast, RBC cast, WBC cast, epithelial cast, fatty cast, epithelial cells, WBC’s, RBC’s, spermatozoa, bacteria and various parasites. 12/19/2017 39 SUNIL KUMAR.P

40. Crystals found in Abnormal urine 1.Cystine 2.Tyrosine 12/19/2017 40 SUNIL KUMAR.P

41. Crystals found in Abnormal urine 12/19/2017 41 SUNIL KUMAR.P

42. Other Abnormal Cells & Other formed elements 1.Malignant cells 2.Fungi 3.Parasites 4.Spermatozoa 12/19/2017 42 SUNIL KUMAR.P

43. Bacteria Normal urine- when fresh doesn’t contain bacteria. But some bacteria from the lower urethra and at the meatus , and if the urine is allowed to stand for some time, they will multiply. If a patient has a urinary tract infection, bacteria will be present in greater numbers. Urine collection- aseptically , midstream clean catch specimen . Well mixed uncentrifuged urine also be examined with Gram’s stain. If bacteria are identified in uncentrifuged urine 100,000 organism per ml are present i,e siginificant bacteriuria . 12/19/2017 43 SUNIL KUMAR.P

44. Cont.., Yeast cells ( candida ) are found in urinary tract infection ( diabetes mellitus), but yeast are common contaminants from skin and air. Parasites and parasitic ova may seen in urine sediments as a results of fecal or vaginal contamination. Trichomonas vaginalis Ova – Schistosoma haematobium Larvae- microfilaria. ( Helminthis ) 12/19/2017 44 SUNIL KUMAR.P