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

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
None = Hyaline
Cells = Cellular Cast
Progression




Cellular
Coarse Granular
Fine Granular
Waxy – (Theory)
11
Microscopy – Cast ID

Hyaline Cast

Key Features


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
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

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
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Coarse Granular Cast
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Key Features
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
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
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Microscopy – Cast ID

Waxy Cast

What rapid chemistry
result do you expect to
be positive?

Protein

>3+
19
Microscopy – Artifact

Fibers

Key Features

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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
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Case History Answer Sheet

1. ________________

6. ________________

2. ________________
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7. ________________
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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