Urinary sediments under microscopic examination

Microscopic examination of urine

1. Urinary sediments under microscopic examination Presenter: Dr. ARNAB NANDY; MBBS, MD (Pediatrics) 1 ST YEAR DrNB Trainee (Nephrology), MSHK, Kolkata

2. INTRODUCTION - Urine collection for microscopic examination: Timing of examination and preservation for transport: Processing before microscopic examination: 2000 rpm, 5 minutes Low and high power objective examination:

3. Objectives for M/E - Red cells, Pus cells (leucocytes), renal epithelial cells Various casts Various crystals Others: various micro-organisms Urinary sediments

4. Urinary sediments Un-organised sediments Organised sediments

5. Un-organised sediments - Factors affecting formation of urinary crystals: Normal/Abnormal pH of urine – Acidic/Alkaline/Neutral Renal diseases – Site & nature of affliction Systemic diseases

6. Urinary crystals - A. Crystals in ACIDIC urine: Amorphous urates Crystalline urates Crystalline uric acid Calcium oxalate B. Crystals in ALKALINE urine: Amorphous phosphates Crystalline phosphates Calcium carbonate Ammonium biurate C. Others: Leucine and tyrosine crystals, Cysteine crystals, Drug crystals

7. Amorphous urates (Reddish-yellow granules) Crystalline urates (Brownish needles, polymorphic)

8. Crystalline uric acid (Yellow or reddish brown; Flat four sided, rhombic plates or prisms) Calcium oxalate (Dumb-bell shaped)

9. Amorphous phosphates (Colourless granules) Crystalline phosphates/ Triple phosphate (Colourless, refractile, six sided prisms)

10. Calcium carbonate (Colourless granules) Ammonium biurate (Yellowish-brown spheres)

11. Bilirubin crystals (Yellowish needle or granules; flash light) Cysteine crystals (Colourless hexagonal; monomorphic) Indinavir crystals (Rectangular plates, needle)

12. Causes Crystal Appearance AKI from ethylene glycol Calcium oxalate mono or di-hydrate Needle or Envelop shaped AKI from uric acid nephropathy Uric acid Diamond shaped, yellow or brown AKI from sulfadiazine Sulfadiazine Needle shaped (shocks of wheat) AKI from acyclovir Acyclovir Needle shaped, birefringent AKI from indinavir Indinavir sulfate / Azatavir Needle shaped; rosettes Urinary crystals associated with acute kidney injury (AKI) Faubel S, Edelstein CL. The patient with acute kidney injury. In: Schrier RW, editors. Manual of nephrology. 8 th Edition. New Delhi: Wolters Kluwer (India) Pvt Ltd; 2019. p. 228-30.

13. Shocks of wheat

14. Organised sediments - Constituents: Tubular casts Epithelial cells Leucocyte or white blood cells Red blood cells (RBCs) Others- micro-organisms, parasites, salts

15. Urinary casts Non-cellular casts Cellular casts

16. Types Characteristics Significance Associated diseases Hyaline casts Colourless, translucent Coagulated protein materials Nonspecific (Exercise, dehydration, benign hypertension and fever) Granular casts Semitransparent containing refractile granules Disintegrated epithelial cells and leucocytes, salts, pigments embedded into coagulated protein materials Nonspecific (Exercise, dehydration, fever, and glomerular and tubular disease ) Glomerulonephritis, pyelonephritis, poisoning, nephrosclerosis Waxy casts Sharply defined, homogeneous, and highly refractile. Broad with broken off borders and indentations Cellular degeneration, tubular inflammation, and extreme urinary stasis Nonspecific (Renal failure casts) Fatty casts Semitransparent or granular cylinder containing large, highly refractile vacuoles or droplets Lipiduria Nephrotic syndrome Bilirubin casts Deep yellow to brown, transparent, granular waxy cylindrical Elevated conjugated bilirubin Obstructive jaundice and liver dysfunction Broad casts Width of two to six times that of other casts, cylindrical; most commonly waxy or granular types Tubular dilation and stasis Advanced renal disease Non-cellular urinary casts

17. Types Characteristics Significance Associated diseases RBC casts Semitransparent or granular cylinder containing distinct erythrocytes Renal parenchymal bleeding, glomerular leakage Acute glomerulonephritis, IgA nephropathy, lupus nephritis, and renal infarction Leucocyte casts Transparent granular or waxy cylinder containing segmented neutrophils Interstitial inflammation Tubulointerstitial disease (pyelonephritis), glomerular disease, interstitial nephritis, and lupus nephritis Epithelial casts Semitransparent granular or waxy cylinder containing intact or necrotic renal tubular epithelial cells Tubular damage Acute tubular necrosis, acute allograft rejection, tubulointerstitial disease, viral disease, and drugs Cellular urinary casts

18. Granular Pigmented casts Matrix (Coagulated proteins) Pigments (embedded) Granularity (fine/coarse)

19. Composition - Matrix Granularity Pigments

20. ‘Muddy brown cast” (…/ lpf )

21. Hyaline cast Granular cast

22. Waxy cast RBC cast

23. Epithelial cast WBC cast

24. TAMM-HORSFALL PROTEIN/UROMODULIN - Glycoprotein secreted by thick ascending loop (TAL) Matrix of renal casts and stones Protective role in acute tubular injury (ATI) Estimation of uromodulin (in urine and serum) and severity of ATI Uromodulin: Creatinine ratio in urine (lower the ratio, higher the injury) Opal SM. Innate Immunity and the Kidney. In: Editor(s): Ronco C, Bellomo R, Kellum JA, Ricci Z. Critical Care Nephrology. 3 rd Edition. New York: Elsevier; 2019. p. 476-82.

25. Clues TO FIND- Physiological or pathological SITE of affliction DURATION of affliction NATURE of affliction

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