Per4.1-04 Urine Sediment Identification
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Transcript Per4.1-04 Urine Sediment Identification
Urine Sediment Identification
Penny S. Stevens, MBS, MT(ASCP), CLS(NCA)
Sr. International QA/QC Medical Technologist
SMILE, Johns Hopkins University
Course Objectives
Review the kidney structure
Review rapid chemical tests
Identify normal and abnormal urine sediment
Review steps for accurate sediment ID
Case studies
2
Kidney Structure - Overview
Approximately 1 million
nephrons in each
kidney
Waste products and
water pass along the
tubule
Water, salts, sugar, &
other large molecules
reabsorbed within limits.
Excess products &
Urine are excreted.
3
Rapid Chemical Test
Bilirubin
Blood
Glucose
Ketones
pH
Protein
Urobilinogen
Nitrite
Leukocytes
Specific Gravity
4
Normal & Abnormal
Microscopy Review
Cells
Casts
Uric Acid Crystals
Crystals
RBC’s & WBC’s
Epithelial Cast
5
Microscopy - Cells
Red Blood Cell
What rapid chemistry
result do you expect to
be positive?
Blood
Leukocyte Esterase
Possibly Nitrite
6
Microscopy - Cells
White Blood Cell
What rapid chemistry
result do you expect to
be positive?
Leukocyte Esterase
7
Microscopy - Cells
Squamous Epithelial
What rapid chemistry
result do you expect to
be positive?
Possibly Nitrite
8
Microscopy - Cells
Renal Epithelial
What rapid chemistry
result do you expect to
be positive?
Possibly Protein
9
Kidney Structure – Cast
Formation
Protein – Tamm-Horsfall
T-H Protein, albumin &
immunoglobulin
Secreted by tubule cells
Distal convoluted tubule
(DCT).
Combine to form cast
Include tubule contents
Illustration:
Protein secretion (green
dots)
Hyaline cast (formed in the
collecting duct.
10
Cast Formation
DST protein secretion
Tubule contents
wrapped into protein
matrix
None = Hyaline
Cells = Cellular Cast
Progression
Cellular
Coarse Granular
Fine Granular
Waxy – (Theory)
11
Microscopy – Cast ID
Hyaline Cast
Key Features
Transparent
Cylindrical
Rounded Ends
Colorless
Homogenous
Nearly Parallel sides
No Dark Edges
12
Microscopy – Cast ID
Hyaline Cast
What rapid chemistry
result do you expect to
be positive?
Protein:
Negative – 1+
13
Microscopy – Cast ID
Cellular Cast – (Renal)
Key Features
Cellular: Few – Numerous
Cylindrical
Rounded Ends
Color – depends on the
contents
Nearly Parallel sides
No Dark Edges
14
Microscopy – Cast ID
Fatty Cast – Polarized
Light
Starch - Polarized
Maltese cross
Similar to starch
What rapid chemistry result
do you expect to be
positive?
Protein
Other rapid chemistriesDepends on the contents15
Fat - Polarized
Microscopy – Cast ID
Granular Cast
Coarse Granular Cast
Key Features
Fine Granular Cast
Coarse - black
Fine – grey/pale yellow
Cellularity Indeterminate
Cylindrical
Rounded Ends
Nearly Parallel sides
No Dark Edges
16
Microscopy – Cast ID
Granular Cast
(Hemoglobin)
What rapid chemistry
result do you expect to
be positive?
Protein
Other - Depends on
the origin:
Blood/Hemoglobin
17
Microscopy – Cast ID
Waxy Cast
Key Features
Opaque (Refractive)
Homogeneous (non-cellular)
At Least One Flat/Blunt End
Short
Possibly Cracked, Serrated or
Convoluted
Nearly Parallel Sides
18
Microscopy – Cast ID
Waxy Cast
What rapid chemistry
result do you expect to
be positive?
Protein
>3+
19
Microscopy – Artifact
Fibers
Key Features
Refractile
Flat
Parallel Sides
Dark Edges
20
Cast Comparison
Hyaline Cast
Transparent
Cylindrical
Rounded Ends
Waxy Cast
Opaque
Cylindrical
Blunt Ends
Fiber
Refractile
Flat
Dark Edges21
Urine Sediment Training
Questions??
22
Microscopy – Crystal ID
Triple Phosphate
Tyrosine
Identify pH
Review Rapid
Chemistry UA
Clinical History
Bilirubin
Calcium Oxalate
Cholesterol
23
Cystine
Crystal pH Chart
24
Common Acidic Crystals
Amorphous Urates
Uric Acid
Calcium Oxalate
25
Abnormal
Acidic Crystals
Bilirubin
Tyrosine
Cystine
Cholesterol
Leucine
26
Uncommon
Acid Crystals
Calcium Sulfates
Sodium Urate
Hippuric Acid
X-Ray Dye (Hypaque)
X-Ray Dye (Renografin)
Sulfonamide
27
Common Alkaline Crystals
Triple Phosphate
Calcium Oxalate
Amorphous
Phosphates
28
Uncommon Alkaline Crystals
Calcium
Phosphate
Ammonium
Biurate
Calcium
Carbonate
29
Case History Answer Sheet
1. ________________
6. ________________
2. ________________
7. ________________
3. ________________
8. ________________
4. ________________
9. ________________
5. ________________
10. _______________
30
Case History - 1
24-year-old female
patient. Asymptomatic
UA during a physical
exam.
Rapid Chemistry
SG = 1.016
pH = 6.0
Blood, Protein, Glucose, &
Leukocyte Esterase =
Negative
31
Common Acidic Crystals
Amorphous Urates
Uric Acid
Calcium Oxalate
32
Abnormal
Acidic Crystals
Bilirubin
Tyrosine
Cystine
Cholesterol
Leucine
33
Uncommon
Acid Crystals
Calcium Sulfates
Sodium Urate
Hippuric Acid
X-Ray Dye (Hypaque)
X-Ray Dye (Renografin)
Sulfonamide
34
Case History - 2
48-year old male found
incoherent and
hospitalized.
Rapid Chemistries
Cloudy urine
Blood 2+
Protein 4+
Nitrite & Leukocyte
Esterase = Positive
35
Cast Comparison
Hyaline Cast
Transparent
Cylindrical
Rounded Ends
Waxy Cast
Opaque
Cylindrical
Blunt Ends
Fiber
Refractile
Flat
Dark Edges36
Case History - 3
63-year old male with
lower back pain.
Rapid Chemistries
pH 5.0
Nitrite = Positive
Protein, Blood,
Leukocyte Esterase,
Glucose, Ketones =
Negative
37
Case History - 4
45-year old male with
chronic hepatitis.
Rapid Chemistries
Specific Gravity = 1.015
pH 5.5
Bilirubin = Positive
Protein = 3+
Leukocyte Est. = Positive
Nitrite, Blood, Glucose,
Ketones = Negative
38
Common Acidic Crystals
Amorphous Urates
Uric Acid
Calcium Oxalate
39
Abnormal
Acidic Crystals
Bilirubin
Tyrosine
Cystine
Cholesterol
Leucine
40
Uncommon
Acid Crystals
Calcium Sulfates
Sodium Urate
Hippuric Acid
X-Ray Dye (Hypaque)
X-Ray Dye (Renografin)
Sulfonamide
41
Case History - 5
19-year old female.
Asymptomatic with UA
during a physical exam.
Rapid Chemistries
pH 6.5
Blood = 1+
Protein = Trace
Leukocyte Est., Nitrite,
Glucose, Ketones = Negative
42
Cast Comparison
Hyaline Cast
Transparent
Cylindrical
Rounded Ends
Waxy Cast
Opaque
Cylindrical
Blunt Ends
Fiber
Refractile
Flat
Dark Edges43
Case History - 6
25-year old female admitted
for multiple substance
abuse.
Rapid Chemistries
Cloudy
pH 6.5
Protein = Trace
Leukocyte Est., Nitrite, Blood,
Glucose & Ketones =
Negative
44
Common Acidic Crystals
Amorphous Urates
Uric Acid
Calcium Oxalate
45
Abnormal
Acidic Crystals
Bilirubin
Tyrosine
Cystine
Cholesterol
Leucine
46
Uncommon
Acid Crystals
Calcium Sulfates
Sodium Urate
Hippuric Acid
X-Ray Dye (Hypaque)
X-Ray Dye (Renografin)
Sulfonamide
47
Case History - 7
52-year old female
admitted for renal
disease.
Rapid Chemistries
pH 5.0
Protein = 3+
Specific Gravity = 1.030
Leukocyte Est., Nitrite,
Blood, Glucose, Ketones =
Negative
48
Cast Comparison
Hyaline Cast
Transparent
Cylindrical
Rounded Ends
Waxy Cast
Opaque
Cylindrical
Blunt Ends
Fiber
Refractile
Flat
Dark Edges49
Case History - 8
71-year old male with
alcoholic cirrhosis and
esophageal bleeding.
Rapid Chemistries
pH 5.0
Specific Gravity = 1.030
Protein = 2+
Blood = 2+
Bilirubin = 3+
Leukocyte Est. = Negative
Nitrite & Glucose = Negative
50
Cast Comparison
Granular
Cast
Cellular Cast (Renal)
Cellular
Cylindrical
Rounded Ends
Cellularity Indeterminate
Cylindrical
Rounded Ends
51
Case History - 9
20-year old female with
acute pyelonephritis (renal
Infection).
Rapid Chemistries
pH 5.0
Nitrite = Positive
Protein = 2+
Leukocyte Esterase = Positive
Blood, Bilirubin, Ketones &
Glucose = Negative
52
Cast Comparison
Granular
Cast
Cellular Cast (Renal)
Cellular
Cylindrical
Rounded Ends
Cellularity Indeterminate
Cylindrical
Rounded Ends
53
Case History - 10
20-year old male.
Asymptomatic with UA
performed during a physical
exam.
Rapid Chemistries
pH 7.5
Protein = Trace
Leukocyte Esterase, Nitrite,
Blood, Bilirubin, Ketones &
Glucose = Negative
54
Alkaline Crystals
Calcium Oxalate
Calcium
Carbonate
Ammonium
Biurate
Amorphous
Phosphates
Triple Phosphate
Calcium
Phosphate
55
Urine Sediment Training
Questions??
Any one need to look at a slide again??
Let’s review our case studies.
56
Case History - 1
24-year-old female
patient. Asymptomatic
UA during a physical
exam.
Rapid Chemistry
Uric Acid
SG = 1.016
pH = 6.0
Blood, Protein, Glucose, &
Leukocyte Esterase =
Negative
57
Case History - 2
48-year old male found
incoherent and
hospitalized.
Rapid Chemistries
Waxy Cast
Cloudy urine
Blood 2+
Protein 4+
Nitrite & Leukocyte
Esterase = Positive
58
Case History - 3
63-year old male with
lower back pain.
Rapid Chemistries
Fibers
pH 5.0
Nitrite = Positive
Protein, Blood,
Leukocyte Esterase,
Glucose, Ketones =
Negative
59
Case History - 4
45-year old male with
chronic hepatitis.
Rapid Chemistries
Bilirubin
Specific Gravity = 1.015
pH 5.5
Bilirubin = Positive
Protein = 3+
Leukocyte Est. = Positive
Nitrite, Blood, Glucose,
Ketones = Negative
60
Case History - 5
19-year old female.
Asymptomatic with UA
during a physical exam.
Rapid Chemistries
Hyaline Cast
pH 6.5
Blood = 1+
Protein = Trace
Leukocyte Est., Nitrite,
Glucose, Ketones = Negative
61
Case History - 6
25-year old female admitted
for multiple substance
abuse.
Rapid Chemistries
Calcium Oxalate
Cloudy
pH 6.5
Protein = Trace
Leukocyte Est., Nitrite, Blood,
Glucose & Ketones =
Negative
62
Case History - 7
52-year old female
admitted for renal
disease.
Rapid Chemistries
Waxy Cast
pH 5.0
Protein = 3+
Specific Gravity = 1.030
Leukocyte Est., Nitrite,
Blood, Glucose, Ketones =
Negative
63
Case History - 8
71-year old male with
alcoholic cirrhosis and
esophageal bleeding.
Rapid Chemistries
Cellular
Cast,RBC
pH 5.0
Specific Gravity = 1.030
Protein = 2+
Blood = 2+
Bilirubin = 3+
Leukocyte Est. = Negative
Nitrite & Glucose = Negative
64
Case History - 9
20-year old female with
acute pyelonephritis (renal
Infection).
Rapid Chemistries
Cellular Cast, WBC
pH 5.0
Nitrite = Positive
Protein = 2+
Leukocyte Esterase = Positive
Blood, Bilirubin, Ketones &
Glucose = Negative
65
Case History - 10
20-year old male.
Asymptomatic with UA
performed during a physical
exam.
Rapid Chemistries
Triple Phosphate
pH 7.5
Protein = Trace
Leukocyte Esterase, Nitrite,
Blood, Bilirubin, Ketones &
Glucose = Negative
66
Urine Sediment Training
Questions?
67
References
Graff, Laurine; A Handbook of Routine
Urinalysis; The Lippencott Company, 1983
http://library.med.utah.edu/WebPath/TUTOR
IAL/URINE/URINE.html
http://www.medicine.uiowa.edu/cme/clia/mo
dules.asp?testID=20
http://www.agora.crosemont.qc.ca/urinesedi
ments/doceng/doc_028.htm
68
References
http://www.med.osaka-u.ac.jp/pub/hplab/www/atlas/ECONTENTS.html
69