Chapter 6: Microscopic Examination of Urine

Multiple Choice

1. The recommended centrifugation setting for preparation of the urine sediment is:
A. 400 RPM for 10 minutes
B. 1000 RPM for 5 minutes
C. 400 RCF for 5 minutes
D. 1000 RCF for 10 minutes

ANS: C
DIF: Level 1
OBJ: 3
TOP: Centrifugation

2. The number of fields that should be examined when quantitating urinary sediment constituents is:
A. 2
B. 5
C. 10
D. 20

ANS: C
DIF: Level 1
OBJ: 3
TOP: Examination of the sediment

3. The predecessor of the standardized urine microscopic examination was the:

A. Sternheimer count
B. Addis count
C. Kova system
D. T-system

ANS: B
DIF: Level 1
OBJ: 3
TOP: Technique

4. The two factors that determine relative centrifugal force are:

A. Radius of rotor head and revolutions per minute (RPM)
B. Radius of rotor head and time of centrifugation
C. Diameter of rotor head and RPM
D. RPM and time of centrifugation

ANS: A
DIF: Level 1
OBJ: 3
TOP: Centrifugation

5. A lipid droplet that does not stain with Sudan III may be composed of:
A. Triglycerides
B. Cholesterol
C. Neutral fats
D. Chylomicrons

ANS: B
DIF: Level 1
OBJ: 4
TOP: Sediment stains

6. A urine specimen is referred for cytodiagnostic urine testing to detect the presence of:
A. Trichomonas vaginalis
B. Blitter cells
C. Malignant cells
D. Spermatozoa

ANS: C
DIF: Level 1
OBJ: 5
TOP: Examining the sediment

7. To standardize the sediment concentration for microscopic analysis one must:

A. Centrifuge the entire urine collection
B. Use only the urine tubes and pipettes for a single commercial system
C. Interchange the urine tubes and pipettes from several commercial systems
D. Use only the parts of the commercial system that you want

ANS: B
DIF: Level 1
OBJ: 3
TOP: Commercial systems

8. The purpose of scanning the perimeter of urine sediment placed under a conventional glass slide is to:
A. Identify types of casts
B. Detect renal tubular epithelial cells
C. Evaluate the overall sediment composition
D. Detect the presence of casts

ANS: D
DIF: Level 1
OBJ: 2
TOP: Examining the sediment

9. All of the following are reported as the quantity per high-power field except:
A. Casts
B. Red blood cells (RBCs)
C. White blood cells (WBCs)
D. Bacteria

ANS: A
DIF: Level 1
OBJ: 3
TOP: Microscopic examination

10. The most probable structures to be stained by the Prussian blue stain are:
A. Renal tubular epithelial cells
B. WBCs
C. Transitional epithelial cells
D. Urothelial cells

ANS: A
DIF: Level 2
OBJ: 4
TOP: Sediment stains

11. The purpose of including glucose as a significant chemical parameter by a laboratory that performs
macroscopic screening is to check for the presence of:
A. WBC casts
B. Hyaline casts
C. Trichomonas vaginalis
D. Candida albicans

ANS: D
DIF: Level 2
OBJ: 3
TOP: Macroscopic screening

12. 10 mL of urine is centrifuged, and 9.5 mL of urine is decanted. The sediment concentration factor is:
A. 5
B. 12
C. 20
D. 24

ANS: C
DIF: Level 2
OBJ: 3
TOP: Commercial systems

13. Calculation of the number of RBCs per milliliter of urine requires knowledge of all of the following
except the:
A. Number of high-power fields per milliliter of urine
B. Speed of centrifugation
C. Number of high-power fields per viewing area
D. Area of a high-power field

ANS: B
DIF: Level 2
OBJ: 3
TOP: Technique

14. A medical laboratory science student consistently obtains lower RBC counts than the instructor. A
possible reason for this might be:
A. Failure to completely resuspend the sedimented specimen
B. Reading the same cells twice
C. Counting all crenated cells twice
D. Using too much stain

ANS: A
DIF: Level 3
OBJ: 3
TOP: Technique

15. Centrifugation of less than the recommended 12 mL of urine for the microscopic examination will:
A. Produce a false-negative sulfosalicyclic acid (SSA)
B. Produce a false-positive SSA
C. Increase the number of cellular elements
D. Decrease the number of cellular elements

ANS: D
DIF: Level 3
OBJ: 3
TOP: Technique
16. Substances found in the urinary sediment that can be confirmed using polarized light are:
A. WBCs
B. Casts
C. Ketone bodies
D. Lipids

ANS: D
DIF: Level 1
OBJ: 6
TOP: Microscopy

17. Using polarized microscopy, which of the following is/are birefringent?

A. Cholesterol
B. Triglycerides
C. Fatty acids
D. Neutral fats

ANS: A
DIF: Level 1
OBJ: 6
TOP: Microscopy

18. Identification of oval fat bodies can be verified using:

A. Bright-field microscopy
B. Phase contrast
C. Polarized light
D. Interference-contrast microscopy

ANS: C
DIF: Level 1
OBJ: 6
TOP: Microscopy

19. Using a bright-field microscope, the final magnification of a high-power field is:
A. 10X
B. 40X
C. 400X
D. 1000X

ANS: C
DIF: Level 1
OBJ: 6
TOP: Microscopy
20. To detect the presence of casts, the sediment is examined using:
A. Increased light under high power
B. Increased light under low power
C. Reduced light under high power
D. Reduced light under low power

ANS: D
DIF: Level 2
OBJ: 6
TOP: Microscopy

21. Optimal viewing is obtained by performing Kohler illumination adjustment to the:

A. Field diaphragm
B. Condenser
C. Operative diaphragm
D. Rheostat

ANS: B
DIF: Level 2
OBJ: 6
TOP: Microscopy

22. To increase the probability of detecting urine sediment constituents that have a low refractive index,
clinical laboratories often use:
A. Phase-contrast microscopy
B. Polarizing microscopy
C. Interference-contrast microscopy
D. Bright-field microscopy

ANS: A
DIF: Level 2
OBJ: 6
TOP: Microscopy

23. The presence of crenated RBCs in the urine sediment is associated with:
A. Rrauma
B. Hypersthenuria
C. Hyposthenuria
D. Urinary tract infection

ANS: B
DIF: Level 1
OBJ: 8
TOP: RBCs

24. Dilute alkaline urine should be examined carefully for the presence of:
A. Yeast
B. Renal tubular epithelial cells
C. Ghost RBCs
D. Fatty casts

ANS: C
DIF: Level 1
OBJ: 8
TOP: RBCs

25. A patient with severe back pain and 15 to 20 RBCs/hpf in the urine sediment may have:
A. Renal calculi
B. Acute glomerulonephritis
C. Nephrotic syndrome
D. Osteomyelitis

ANS: A
DIF: Level 2
OBJ: 8
TOP: RBCs

26. Differentiation among RBCs, yeast, and oil droplets may be accomplished by all of the following
except:
A. Observation of budding in yeast cells
B. Increased refractility of oil droplets
C. Lysis of yeast cells by acetic acid
D. Lysis of RBCs by acetic acid

ANS: C
DIF: Level 2
OBJ: 8
TOP: RBCs

27. Ghost RBCs most frequently occur with a urine specimen that exhibits the following:
A. High pH, high specific gravity
B. High pH, low specific gravity
C. Low pH, high specific gravity
D. Low pH, low specific gravity
ANS: B
DIF: Level 2
OBJ: 8
TOP: RBCs

28. The presence of hypochromic, irregularly shaped RBCs in the urine sediment can indicate:
A. A coagulation disorder
B. Menstrual contamination
C. Urinary tract infection
D. Glomerular bleeding

ANS: D
DIF: Level 2
OBJ: 8
TOP: RBCs

29. Glitter cell is a term used to describe a specific type of:

A. Ketone body
B. Renal tubular epithelial cell
C. Neutrophil
D. Oval fat body

ANS: C
DIF: Level 1
OBJ: 9
TOP: WBCs

30. An increase in urinary WBCs is called:

A. Pyelonephritis
B. Cystitis
C. Urethritis
D. Pyuria

ANS: D
DIF: Level 1
OBJ: 9
TOP: WBCs

31. Urine sediments containing increased WBCs should be observed closely for the presence of:
A. Hyaline casts
B. Granular casts
C. Bacteria
D. Urothelial cells
ANS: C
DIF: Level 1
OBJ: 9
TOP: WBCs

32. Eosinophils are found in the urine in cases of:

A. Nephrotic syndrome
B. Cystitis
C. Acute interstitial nephritis
D. Renal lithiasis

ANS: C
DIF: Level 2
OBJ: 9
TOP: WBCs

33. Leukocytes that stain pale blue with Sternheimer-Malbin stain and exhibit brownian movement are:
A. Indicative of pyelonephritis
B. Basophils
C. Mononuclear leukocytes
D. Glitter cells

ANS: D
DIF: Level 2
OBJ: 9
TOP: WBCs

34. Oval fat bodies are:

A. Squamous epithelial cells that contain lipids
B. Renal tubular epithelial cells that contain lipids
C. WBCs that have phagocytized lipids
D. People who fail to work out regularly

ANS: B
DIF: Level 1
OBJ: 10
TOP: Epithelial cells

35. The type of cells that line the bladder and ureters are called:
A. Squamous
B. Renal tubular
C. Transitional
D. Basal

ANS: C
DIF: Level 1
OBJ: 10
TOP: Epithelial cells

36. Initial microscopic focusing on the urinary sediment is frequently performed by referencing:
A. Mucus
B. Squamous epithelial cells
C. RBCs
D. Hyaline casts

ANS: B
DIF: Level 1
OBJ: 10
TOP: Epithelial cells

37. In ascending order, the location of epithelial cells in the urinary tract is:
A. Squamous, transitional, renal tubular
B. Transitional, renal tubular, squamous
C. Renal tubular, transitional, squamous
D. Squamous, renal tubular, urothelial

ANS: A
DIF: Level 1
OBJ: 10
TOP: Epithelial cells

38. Clue cells are derived from:

A. Renal tubular epithelial cells
B. Trichomonas vaginalis
C. Histiocytes
D. Squamous epithelial cells

ANS: D
DIF: Level 1
OBJ: 10
TOP: Epithelial cells

39. The organisms attached to a clue cell are:

A. Gardnerella vaginalis
B. Trichomonas vaginalis
C. Escherichia coli
D. Candida albicans

ANS: A
DIF: Level 1
OBJ: 10
TOP: Epithelial cells

40. Urothelial cells routinely occur in all of the following shapes except:
A. Spherical
B. Cylindroid
C. Polyhedral
D. Caudate

ANS: B
DIF: Level 1
OBJ: 10
TOP: Epithelial cells

41. Which of the following cells found in increased numbers in the urine sediment is only indicative of
nephron damage?
A. Erythrocytes
B. WBCs
C. Squamous epithelial cells
D. Renal tubular cells

ANS: D
DIF: Level 2
OBJ: 10
TOP: Epithelial cells

42. The type of cell most likely to appear stained with bilirubin is:
A. Renal tubular
B. Neutrophil
C. Squamous
D. Transitional

ANS: A
DIF: Level 2
OBJ: 10
TOP: Epithelial cells

43. Collection of a midstream clean-catch specimen will alleviate contamination by:

A. Renal tubular epithelial cells
B. RBCs
C. Transitional epithelial cells
D. Squamous epithelial cells

ANS: D
DIF: Level 2
OBJ: 10
TOP: Epithelial cells

44. Which of the following cells can both be found in both a vaginal wet prep and in urine sediment?
A. Yeast cell and clue cell
B. Transitional and renal epithelial cell
C. Clue cell and squamous cell
D. Renal and squamous cells

ANS: A
DIF: Level 2
OBJ: 10
TOP: Epithelial cells

45. Spherical transitional epithelial cells can be differentiated from renal tubular epithelial cells by
observing the:
A. Centrally located nucleus in renal tubular cells
B. Granular cytoplasm in renal tubular cells
C. Centrally located nucleus in transitional cells
D. Granular cytoplasm in transitional cells

ANS: C
DIF: Level 2
OBJ: 10
TOP: Epithelial cells

46. The finding of renal tubular epithelial cells containing yellow-brown granules correlates with a
positive reagent strip test for:
A. Blood
B. Bilirubin
C. Glucose
D. Nitrite

ANS: A
DIF: Level 2
OBJ: 10
TOP: Epithelial cells
47. The primary factor that favors the formation of urinary casts is:
A. Urinary stasis
B. High pH
C. Positive blood
D. Low specific gravity

ANS: A
DIF: Level 1
OBJ: 12
TOP: Casts

48. The major constituent of urinary casts is:

A. Lipoprotein
B. Bence Jones protein
C. Uromodulin protein
D. Amino acids

ANS: C
DIF: Level 1
OBJ: 12
TOP: Casts

49. Waxy casts are most easily differentiated from hyaline casts by their:
A. Color
B. Size
C. Granules
D. Refractivity

ANS: D
DIF: Level 1
OBJ: 13
TOP: Casts

50. Urinary casts are formed in the:

A. Distal and collecting tubules
B. Distal tubules and loops of Henle
C. Proximal and distal tubules
D. Proximal tubules and loops of Henle

ANS: A
DIF: Level 1
OBJ: 13
TOP: Casts
51. Which of the following elements would most likely be found in an acidic concentrated urine that
contains protein?
A. Ghost RBCs
B. Casts
C. Bacteria
D. Triple phosphate crystals

ANS: B
DIF: Level 1
OBJ: 13
TOP: Casts

52. Sediment constituents that are used to differentiate between upper and lower urinary tract infections
are:
A. WBCs
B. WBC clumps
C. RBCs and WBCs
D. WBC casts

ANS: D
DIF: Level 1
OBJ: 13
TOP: Casts

53. To differentiate a bacterial cast from a granular cast, a clinical laboratory scientist could:
A. Perform a Gram stain
B. Use polarizing microscopy
C. Perform a Hansel stain
D. Add acetic acid to the sediment

ANS: A
DIF: Level 2
OBJ: 13
TOP: Casts

54. The type of cast most closely associated with tubular damage is the:
A. WBC cast
B. Epithelial cell cast
C. RBC cast
D. Fatty cast

ANS: B
DIF: Level 1
OBJ: 13
TOP: Casts

55. The only type of cast capable of polarization is the:

A. Waxy cast
B. Hyaline cast
C. Fatty cast
D. Granular cast

ANS: C
DIF: Level 1
OBJ: 13
TOP: Casts

56. Broad casts may form as a result of:

A. Extreme urinary stasis
B. Strenuous exercise
C. Increase in loss of amino acids
D. Dehydration

ANS: A
DIF: Level 1
OBJ: 13
TOP: Casts

57. The finding of increased hyaline and granular casts in the urine of an otherwise healthy person may be
the result of:
A. Fecal contamination
B. Recent strenuous exercise
C. Early urinary tract infection
D. Analyzing an old specimen

ANS: B
DIF: Level 2
OBJ: 13
TOP: Casts

58. Hyaline casts may degenerate into:

A. Granular casts
B. Fatty casts
C. Broad casts
D. Waxy casts
ANS: D
DIF: Level 2
OBJ: 13
TOP: Casts

59. Waxy casts can be found in the urine sediment:

A. In patients with renal failure
B. Of an alkaline urine
C. Whenever abnormal protein is present
D. When urine is not correctly preserved

ANS: A
DIF: Level 2
OBJ: 13
TOP: Casts

60. The urinary sediment constituent most closely associated with bleeding within the nephron is the:
A. RBC
B. RBC cast
C. WBC cast
D. Hyaline cast

ANS: B
DIF: Level 2
OBJ: 13
TOP: Casts

61. Which of the following differentiates a waxy cast from a fiber most effectively?
A. Waxy casts do not polarize light, and fibers do.
B. Waxy casts are more refractile than fibers.
C. Waxy casts have rounded ends, and fibers do not.
D. Waxy casts are thicker on the edge, and fibers are thicker in the center.

ANS: A
DIF: Level 2
OBJ: 13
TOP: Casts

62. All of the following may be seen in the urine following strenuous exercise except:
A. Protein
B. Glucose
C. Hyaline casts
D. Granular casts

ANS: B
DIF: Level 2
OBJ: 13
TOP: Casts

63. To distinguish a cellular cast from a clump of cells, the clinical laboratory scientist should:
A. Check for dysmorphic cells
B. Look carefully for a cast matrix
C. Determine if free-standing cells are present
D. Examine the sediment using polarizing microscopy

ANS: B
DIF: Level 2
OBJ: 13
TOP: Casts

64. Granular casts present in the urine following strenuous exercise can:
A. Represent disintegration of cellular casts
B. Contain cellular lysosomes
C. Be pathogenic for renal disease
D. Represent a prerenal condition

ANS: B
DIF: Level 2
OBJ: 13
TOP: Casts

65. All of the following are associated with severe urinary stasis except:
A. Granular casts
B. Waxy casts
C. WBC casts
D. Broad casts

ANS: C
DIF: Level 2
OBJ: 13
TOP: Casts

66. Identification of urinary crystals is based on shape and:

A. Urine pH and crystal solubility
B. Urine protein and crystal size
C. Urine bilirubin and glucose
D. Urine pH and crystal size

ANS: A
DIF: Level 1
OBJ: 14
TOP: Urinary crystals

67. Urinary crystals that appear yellow to reddish-brown are:

A. Calcium oxalate
B. Triple phosphate
C. Cholesterol
D. Uric acid

ANS: D
DIF: Level 1
OBJ: 14
TOP: Urinary crystals

68. To dissolve amorphous urates, you could:

A. Warm the specimen to body temperature
B. Add concentrated sodium hydroxide
C. Add dilute hydrochloric acid
D. Add dilute acetic acid

ANS: A
DIF: Level 1
OBJ: 14
TOP: Urinary crystals

69. Nonpathogenic or “normal” crystals found in acidic urine include:

A. Calcium oxalate, uric acid, amorphous urates
B. Calcium oxalate, uric acid, sulfonamides
C. Uric acid, amorphous urates, triple phosphate
D. Uric acid, calcium carbonate, bilirubin

ANS: A
DIF: Level 1
OBJ: 14
TOP: Urinary crystals

70. All of the following crystals can be found in acid urine except:
A. Cholesterol
B. Tyrosine
C. Cystine
D. Ammonium biurate

ANS: D
DIF: Level 1
OBJ: 14
TOP: Urinary crystals

71. Abnormal crystals are most frequently seen in a urine that is:
A. Acid
B. Neutral
C. Alkaline
D. Collected for 24 hours

ANS: A
DIF: Level 1
OBJ: 14
TOP: Urinary crystals

72. Information that aids in the identification of crystals includes all of the following except:
A. Urine temperature
B. Urine pH
C. Crystal solubility
D. Crystal birefringence

ANS: A
DIF: Level 1
OBJ: 14
TOP: Urinary crystals

73. Which of the following crystals occurs in two very distinct forms?
A. Ammonium biurate
B. Calcium oxalate
C. Leucine
D. Cholesterol

ANS: B
DIF: Level 1
OBJ: 14
TOP: Urinary crystals

74. Nonpathogenic or “normal” crystals found in alkaline urine include:

A. Calcium oxalate, uric acid, amorphous urates
B. Calcium oxalate, uric acid, sulfonamides
C. Uric acid, amorphous urates, calcium carbonate
D. Triple phosphate, calcium carbonate, ammonium biurate

ANS: D
DIF: Level 2
OBJ: 15
TOP: Urinary crystals

75. Crystals found in the urine that are associated with pathogenic disease include:
A. Calcium oxalate and uric acid
B. Leucine and tyrosine
C. Heavy amorphous phosphates
D. Triple phosphate and ammonium biurate

ANS: B
DIF: Level 2
OBJ: 16
TOP: Urinary crystals

76. Which of the following crystals is associated with ethylene glycol ingestion?
A. Uric acid
B. Calcium oxalate monohydrate
C. Triple phosphate
D. Calcium oxalate dihydrate

ANS: B
DIF: Level 2
OBJ: 14
TOP: Urinary crystals

77. A urine specimen refrigerated overnight is cloudy and has a pH of 6. The turbidity is probably due to:
A. Amorphous phosphates
B. Amorphous urates
C. Triple phosphate crystals
D. Calcium oxalate crystals

ANS: B
DIF: Level 2
OBJ: 14
TOP: Urinary crystals
78. All of the following affect the formation of crystals except:
A. Urine specific gravity
B. Urine pH
C. Urinary casts
D. Urine temperature

ANS: C
DIF: Level 2
OBJ: 14
TOP: Urinary crystals

79. Cystine crystals are often confused with:

A. Cholesterol crystals
B. Leucine crystals
C. Uric acid crystals
D. Triple phosphate crystals

ANS: C
DIF: Level 2
OBJ: 16
TOP: Urinary crystals

80. Formation of crystals due to medications is most frequently caused by:

A. Inadequate hydration
B. Incorrect timing of medication doses
C. Medication overdoses
D. Use of expired antibiotics

ANS: A
DIF: Level 2
OBJ: 16
TOP: Urinary crystals

81. Calcium carbonate crystals can be distinguished from bacteria by:

A. Warming the sediment
B. Refrigerating the specimen
C. Checking the pH of the specimen
D. Adding acetic acid

ANS: D
DIF: Level 2
OBJ: 15
TOP: Urinary crystals
82. Which of the following results should have testing repeated?
A. Positive blood and protein
B. pH 7.0 with uric acid crystals
C. Positive bilirubin and urobilinogen
D. pH 8.0, WBCs, and triple phosphate crystals

ANS: B
DIF: Level 3
OBJ: 14
TOP: Urinary crystals

83. The significance of seeing bacteria in the urine sediment is increased when:
A. RBCs and casts are present
B. The patient has an elevated temperature
C. The specimen is cloudy
D. WBCs are present

ANS: D
DIF: Level 1
OBJ: 18
TOP: Urinary sediment artifacts

84. Yeast may appear in the urine sediment in all of the following forms except:
A. Mycelial
B. Biconcave
C. Oval
D. Budding ovals

ANS: B
DIF: Level 1
OBJ: 17
TOP: Urinary sediment artifacts

85. Schistosoma haematobium would most likely be found in the urine from a:
A. Foreign-service employee
B. Marathon runner
C. Diabetic patient
D. Health-care worker

ANS: A
DIF: Level 1
OBJ: 17
TOP: Urinary sediment artifacts
86. Motility by which of the following is most noticeable during the urine sediment examination?
A. Spermatozoa
B. Candida albicans
C. Trichomonas vaginalis
D. Escherichia coli

ANS: C
DIF: Level 1
OBJ: 18
TOP: Urinary sediment artifacts

87. Urine sediment artifacts frequently differ from true sediment constituents by their:
A. Location in the specimen
B. Appearance
C. Refractility
D. Number present

ANS: C
DIF: Level 1
OBJ: 18
TOP: Urinary sediment artifacts

88. Under polarized light, all of the following will exhibit the Maltese cross formation except:
A. Starch granules
B. Oval fat bodies
C. Pollen grains
D. Fatty casts

ANS: C
DIF: Level 2
OBJ: 17
TOP: Urinary sediment artifacts

89. In an unpreserved and old urine specimen, there could be difficulty differentiating between bacteria
and:
A. Yeast
B. Mucus
C. Amorphous phosphates
D. Pollen grains

ANS: C
DIF: Level 2
OBJ: 17
TOP: Urinary sediment artifacts

90. Which of the following is most likely to be found in the urine of a diabetic patient?
A. Trichomonas vaginalis
B. Escherichia coli
C. Staphylococcus saprophyticus
D. Candida albicans

ANS: D
DIF: Level 2
OBJ: 18
TOP: Urinary sediment artifacts

91. Specimens containing mucus may be erroneously reported as containing:

A. Bacteria
B. Yeast
C. Hyaline casts
D. Oval fat bodies

ANS: C
DIF: Level 2
OBJ: 17
TOP: Urinary sediment artifacts

NARRBEGIN: 06-nar-01
Choose the appropriate urine sediment stain for the following functions:
NARREND

92. Enhance nuclear detail.

A. Sudan III
B. Hansel stain
C. Prussian blue
D. Toluidine blue

ANS: D
NAR: 06-nar-01
DIF: Level 1
OBJ: 4
TOP: Sediment stains

93. Stain oval fat bodies.

A. Sudan III
B. Hansel stain
C. Prussian blue
D. Sternheimer-Malbin

ANS: A
NAR: 06-nar-01
DIF: Level 1
OBJ: 4
TOP: Sediment stains

94. Stain eosinophils.

A. Sudan III
B. Hansel stain
C. Prussian blue
D. Toluidine blue

ANS: B
NAR: 06-nar-01
DIF: Level 1
OBJ: 4
TOP: Sediment stains

95. Stain hemosiderin granules.

A. Hansel stain
B. Prussian blue
C. Toluidine blue
D. Sternheimer-Malbin

ANS: B
NAR: 06-nar-01
DIF: Level 1
OBJ: 4
TOP: Sediment stains

NARRBEGIN: 06-nar-02
The following results are obtained on a urinalysis from a student athlete:
NARREND

96. Based on the information given, what is causing the crenated RBCs?
A. Elevated protein
B. Presence of hyaline casts
C. High specific gravity
D. Presence of granular casts

ANS: C
NAR: 06-nar-02
DIF: Level 2
OBJ: 18
TOP: Microscopic case study

97. Based on the information provided, why is only a trace of blood detected by reagent strip?
A. Protein inhibition
B. Acid pH
C. Crenated RBCs
D. Dilute specimen

ANS: C
NAR: 06-nar-02
DIF: Level 3
OBJ: 18
TOP: Microscopic case study

98. Based on the information provided, name another form of RBC that could be present in this urine
sediment.
A. Glitter cells
B. Spherocytes
C. Hypochromic
D. Dysmorphic

ANS: D
NAR: 06-nar-02
DIF: Level 3
OBJ: 18
TOP: Microscopic case study

99. Based on the information provided, what is the most probable cause of the abnormal results?
A. Sports injury
B. Glomerular damage
C. Strenuous exercise
D. Dehydration

ANS: C
NAR: 06-nar-02
DIF: Level 3
OBJ: 18
TOP: Microscopic case study

100. Based on the information provided, what type of specimen should the student be asked to collect for
retesting?
A. First morning
B. Timed 8-hour
C. Midstream clean-catch
D. Second morning

ANS: A
NAR: 06-nar-02
DIF: Level 3
OBJ: 18
TOP: Microscopic case study

NARRBEGIN: 06-nar-03
The following results are obtained on a catheterized specimen from a patient with symptoms of urinary
tract infection:

Color: Yellow Protein: 1+ Blood: Trace

Clarity: Cloudy Glucose: Negative Urobilinogen: 1.0 EU
Specific gravity: 1.015 Ketones: Negative Nitrite: Positive
pH: 7.0 Bilirubin: Negative Leukocyte esterase: 2+
Microscopic
80-100 WBCs hgf 10-15 RTE ceUsyhpf
5-10 RBCs hpf Many bacteria
NARREND
101. Based on information provided, is this report consistent with a urinary tract infection?
A. Yes
B. No

ANS: A
NAR: 06-nar-03
DIF: Level 2
OBJ: 18
TOP: Microscopic case study

102. Based on the information provided, which of these results would concern a urinalysis supervisor?
A. Elevated protein
B. renal tubullar epithelial cells
C. Blood
D. Absence of WBC casts

ANS: B
NAR: 06-nar-03
DIF: Level 2
OBJ: 18
TOP: Microscopic case study

103. Based on the information provided, what is the most probable cause of an error in the report?
A. Specimen mix-up
B. RTEs are spherical transitional cells
C. Analyzing a catheterized specimen
D. Both B and C

ANS: D
NAR: 06-nar-03
DIF: Level 3
OBJ: 18
TOP: Microscopic case study

NARRBEGIN: 06-nar-04
Urinalysis results on a patient being monitored following an adverse reaction occurring during surgery
are:
NARREND

104. Based on the information provided, what substance is causing the positive reagent strip reaction for
blood?
A. Hemoglobin
B. Myoglobin
C. RBCs
D. Peroxide contamination

ANS: A
NAR: 06-nar-04
DIF: Level 3
OBJ: 18
TOP: Microscopic case study

105. Based on the information provided, what is the significance of the elevated urobilinogen reading?
A. Constipation
B. Liver damage
C. Intravascular hemolysis
D. Urine color

ANS: C
NAR: 06-nar-04
DIF: Level 3
OBJ: 18
TOP: Microscopic case study

106. Based on the information provided, what is the composition of the dirty, brown casts?
A. Melanin
B. Methemoglobin
C. Coarse granules
D. RBCs
ANS: B
NAR: 06-nar-04
DIF: Level 3
OBJ: 13
TOP: Microscopic case study

107. What is the significance of the RTE cells and casts based on the information provided?
A. Tubular damage
B. Decreased urine flow
C. Glomerular damage
D. Possible malignancy

ANS: A
NAR: 06-nar-04
DIF: Level 3
OBJ: 13
TOP: Microscopic case study

108. What is the probable composition of the yellow-brown granules based on the information provided?
A. Hemoglobin
B. Uric acid
C. Hemosiderin
D. Disintegrating RTE cells

ANS: C
NAR: 06-nar-04
DIF: Level 3
OBJ: 17
TOP: Microscopic case study

109. Based on the information provided, how could the composition of the granules be confirmed?
A. With Prussian blue stain
B. With polarized microscopy
C. With Hansel stain
D. With phase microscopy

ANS: A
NAR: 06-nar-04
DIF: Level 3
OBJ: 18
TOP: Microscopic case study

True/False
110. To adjust the intensity of light in a bright-field microscope, the condenser should be raised or
lowered.

ANS: False
DIF: Level 1
OBJ: 6
TOP: Microscopy

111. When changing magnification using a parfocal microscope, focusing is performed using the coarse
adjustment knob.

ANS: False
DIF: Level 1
OBJ: 6
TOP: Microscopy

112. In the urinalysis laboratory, a bright-field microscope can be converted to a polarizing microscope.

ANS: True
DIF: Level 1
OBJ: 6
TOP: Microscopy

113. The finding of increased urinary WBCs is not significant unless increased bacteria are also present.

ANS: False
DIF: Level 2
OBJ: 9
TOP: WBCs

114. Renal tubular epithelial cells from the distal convoluted tubule are smaller than those from the
proximal convoluted tubule.

ANS: True
DIF: Level 2
OBJ: 10
TOP: Epithelial cells
115. A structure resembling a cast but having a tapered end should not be reported as a cast.

ANS: False
DIF: Level 1
OBJ: 12
TOP: Casts

116. WBC casts should always be accompanied by significant bacteriuria.

ANS: False
DIF: Level 1
OBJ: 13
TOP: Casts

117. To be considered significant, yeast cells in the urine sediment should be accompanied by leukocytes.

ANS: True
DIF: Level 1
OBJ: 17
TOP: Urinary sediment artifacts

118. Trichomonas vaginalis is not found in urine from male patients.

ANS: False
DIF: Level 1
OBJ: 17
TOP: Urinary sediment artifacts

Matching

Choose the correct microscope part needed to perform the following functions:
A. Condenser
B. Oculars
C. Diopter adjustment knob
D. Rheostat
E. Nose piece

119. Focus light on the specimen

120. Hold the objectives
121. Increase objective resolution
122. Control light intensity
123. Regulate interpupillary distance

119. ANS: A DIF: Level 1 OBJ: 6 TOP: Microscopy

120. ANS: E DIF: Level 1 OBJ: 6 TOP: Microscopy
121. ANS: B DIF: Level 1 OBJ: 6 TOP: Microscopy
122. ANS: D DIF: Level 1 OBJ: 6 TOP: Microscopy
123. ANS: C DIF: Level 1 OBJ: 6 TOP: Microscopy

Choose the description for the following urine crystals:

A. Thorny apple
B. Coffin lid
C. Notched corners
D. Hexagonal
E. Dumbbell

124. Ammonium biurate

125. Calcium carbonate
126. Triple phosphate
127. Cystine
128. Cholesterol

124. ANS : A DIF: Level 1 OBJ 15 TOP: Urinary crystals

125. ANS E DIF: Level 1 OBJ 15 TOP: Urinary crystals
126. ANS B DIF: Level 1 OBJ 15 TOP: Urinary crystals
127. ANS D DIF: Level 1 OBJ 16 TOP: Urinary crystals
128. ANS : C DIF: Level 1 OBJ 16 TOP: Urinary crystals

State if a urinalysis supervisor would be concerned or not concerned about the following results:
A. Concerned
B. Not concerned

129. Enterobius vermicularis and waxy casts in a cloudy specimen from a pediatric patient
130. RBC casts in a specimen with a negative reagent strip test for blood
131. Triple phosphate and ammonium biurate crystals in a specimen with a pH of 8.0
132. Candida albicans and leukocytes in a specimen with a negative nitrite test
133. 2-3 granular casts/lpf in a refrigerated specimen containing many amorphous crystals
134. Many budding yeasts in a clear, red specimen from a bedridden, diabetic patient

129. ANS: A DIF: Level 3 OBJ: 13 TOP: Microscopic case

study
130. ANS: A DIF: Level 3 OBJ: 13 TOP: Microscopic case
study
131. ANS: B DIF: Level 3 OBJ: 15 TOP: Microscopic case
study
132. ANS: B DIF: Level 3 OBJ: 17 TOP: Microscopic case
study
133. ANS: A DIF: Level 3 OBJ: 13 TOP: Microscopic case
study
134. ANS: B DIF: Level 3 OBJ: 17 TOP: Microscopic case
study
100 Part Two | Urinalysis

The third part of routine urinalysis, after physical and chemical The patient population must also be considered when develop­
examination, is the microscopic examination of the urinary ing protocols for macroscopic screening. Populations that have
sediment. Its purpose is to detect and to identify insoluble ma­ come under consideration include pregnant women, as well as
terials present in the urine. The blood, kidney, lower genitouri­ pediatric, geriatric, diabetic, immunocompromised, and renal
nary tract, and external contamination all contribute formed patients. The Clinical and Laboratory Standards Institute
elements to the urine. These include red blood cells (RBCs), (CLSI) recommends that microscopic examination be per­
white blood cells (WBCs), epithelial cells, casts, bacteria, yeast, formed when requested by a physician, when a laboratory-
parasites, mucus, spermatozoa, crystals, and artifacts. Because specified patient population is being tested, or when any ab­
some of these components are of no clinical significance and normal physical or chemical result is obtained.3
others are considered normal unless they are present in in­
creased amounts, examination of the urinary sediment must Specimen Preparation
include both identification and quantitation of the elements Specimens should be examined while fresh or adequately pre­
present. Microscopic analysis is subject to several procedural served. Formed elements—primarily RBCs, WBCs, and hya­
variations, including the methods by which the sediment is line casts—disintegrate rapidly, particularly in dilute alkaline
prepared, the volume of sediment actually examined, the urine. Refrigeration may cause precipitation of amorphous
methods and equipment used to obtain visualization, and urates and phosphates and other nonpathologic crystals that
the manner in which the results are reported. Protocols have can obscure other elements in the urine sediment. Warming
been developed to increase the standardization and cost­ the specimen to 37°C prior to centrifuging may dissolve some
effectiveness of microscopic urinalysis, and they are discussed of these crystals.
in this chapter. The midstream clean-catch specimen minimizes external
contamination of the sediment. As with the physical and chem­
ical analyses, dilute random specimens may cause false-negative
k. Macroscopic Screening readings.
To enhance the cost-effectiveness of urinalysis, many labora­ Care must be taken to thoroughly mix the specimen prior
tories have developed protocols whereby microscopic exami­ to decanting a portion into a centrifuge tube.
nation of the urine sediment is performed only on specimens
Specimen Volume
meeting specified criteria. Abnormalities in the physical and
chemical portions of the urinalysis play a primary role in the A standard amount of urine, usually between 10 and 15 mL, is
decision to perform a microscopic analysis, thus the use of centrifuged in a conical tube. This provides an adequate volume
the term “macroscopic screening.” from which to obtain a representative sample of the elements
Parameters considered significant vary among laboratories present in the specimen. A 12-mL volume is frequently used
but usually include color, clarity, blood, protein, nitrite, leuko­ because multiparameter reagent strips are easily immersed in
cyte esterase, and possibly glucose. Laboratory-designated this volume, and capped centrifuge tubes are often calibrated
criteria can also be programed into automated instruments. to this volume.
Table 6-1 illustrates the significance of these parameters. Per­ If obtaining a 12-mL specimen is not possible, as with pe­
centages of abnormal specimens that would go undetected diatric patients, the volume of the specimen used should be
using these parameters differ significantly among studies.1,2 noted on the report form. This allows the physician to correct
the results, if indicated. Some laboratories choose to make this
correction prior to reporting. For example, if 6 mL of urine is
centrifuged, the results are multiplied by 2.
Table 6-1 Macroscopic Screening and Microscopic
■ Correlations
Centrifugation
Screening Test Significance
The speed of the centrifuge and the length of time the speci­
Color Blood men is centrifuged should be consistent. Centrifugation for
Clarity Hematuria versus hemoglobinuria/ 5 minutes at a relative centrifugal force (RCF) of 400 produces
myoglobinuria an optimum amount of sediment with the least chance of dam­
aging the elements. To correct for differences in the diameter
Confirm pathologic or nonpatho-
of centrifuge heads, RCF rather than revolutions per minute
logic cause of turbidity
(RPM) is used. The RPM value shown on the centrifuge
Blood RBCs, RBC casts tachometer can be converted to RCF using nomograms avail­
Protein Casts, cells able in many laboratory manuals or by using the formula:
Nitrite Bacteria, WBCs
RCF = 1.118 x 10-5 x radius in centimeters x RPM2
Leukocyte esterase WBCs, WBC casts, bacteria
Glucose Yeast Centrifugation calibration should be routinely performed.
Use of the braking mechanism to slow the centrifuge causes
 Chapter 6 | Microscopic Examination of Urine 101

disruption of the sediment prior to decantation and should not Urisystem (ThermoFisher Scientific, Waltham, MA), Count-10
be used. (V-Tech, Inc., Pomona, CA), Quick-Prep Urinalysis System
To prevent biohazardous aerosols, all specimens must be (Globe Scientific, Paramus, NJ), CenSlide 2000 Urinalysis
centrifuged in capped tubes. System (International Remote Imaging Systems, Norwood,
MA), and R/S Workstations 1000, 2000, 2003 (DioSys,
Sediment Preparation Waterbury, CA). The systems provide a variety of options
A uniform amount of urine and sediment should remain in the including capped, calibrated centrifuge tubes; decanting
tube after decantation. Volumes of 0.5 and 1.0 mL are fre­ pipettes to control sediment volume; and slides that control
quently used. The volume of urine centrifuged divided by the the amount of sediment examined, produce a consistent
sediment volume equals the concentration factor, which in the monolayer of sediment for examination, and provide cali­
preceding examples are 24 and 12, respectively. The sediment brated grids for more consistent quantitation.
concentration factor relates to the probability of detecting ele­ The Cen-Slide and R/S Workstations do not require man­
ments present in low quantities and is used when quantitating ual loading of the centrifuged specimen onto a slide and are
the number of elements present per milliliter. considered closed systems that minimize exposure to the spec­
To maintain a uniform sediment concentration factor, imen. Cen-Slide provides a specially designed tube that permits
urine should be aspirated off rather than poured off, unless direct reading of the urine sediment. The R/S Workstations
otherwise specified by the commercial system in use. Some consist of a glass flow cell into which urine sediment is
systems provide pipettes for this purpose. The pipettes are also pumped, microscopically examined, and then flushed from the
used for sediment resuspension and transferring specimens to system.
the slide.
The sediment must be thoroughly resuspended by gentle
Examining the Sediment
agitation. This can be performed using a commercial-system Microscopic examination should be performed in a consistent
pipette or by repeatedly tapping the tip of the tube with the manner and include observation of a minimum of 10 fields
finger. Vigorous agitation should be avoided, as it may disrupt under both low (10X) and high (40X) power. The slide is first
some cellular elements. Thorough resuspension is essential examined under low power to detect casts and to ascertain the
to provide equal distribution of elements in the microscopic general composition of the sediment. When elements such as
examination fields. casts that require identification are encountered, the setting is
changed to high power.
Volume of Sediment Examined If the conventional glass-slide method is being used, casts
The volume of sediment placed on the microscope slide have a tendency to locate near the edges of the cover slip;
should be consistent for each specimen. When using the therefore, low-power scanning of the cover-slip perimeter is
conventional glass-slide method, the recommended vol­ recommended. This does not occur when using standardized
ume is 20 p L (0 .02 mL) covered by a 22 X 22 mm glass commercial systems.
cover slip. Allowing the specimen to flow outside of the When the sediment is examined unstained, many sedi­
cover slip may result in the loss of heavier elements such ment constituents have a refractive index similar to urine.
as casts. Therefore, it is essential that sediments be examined under
Commercial systems control the volume of sediment ex­ reduced light when using bright-field microscopy.
amined by providing slides with chambers capable of contain­ Initial focusing can be difficult with a fluid specimen, and
ing a specified volume. Care must be taken to ensure the care must be taken to ensure that the examination is being per­
chambers are completely filled. Product literature supplies the formed in the correct plane. Often an epithelial cell will be
chamber volume, size of the viewing area, and approximate present to provide a point of reference. Focusing on artifacts
number of low-power and high-power viewing areas, based should be avoided, because they are often larger than the reg­
on the area of the field of view using a standard microscope. ular sediment elements and cause the microscopist to examine
This information, together with the sediment concentration objects in the wrong plane. Continuous focusing with the fine
factor, is necessary to quantitate cellular elements per milliliter adjustment aids in obtaining a complete representation of the
of urine. sediment constituents.

Commercial Systems ~ Reporting the Microscopic Examination

The conventional method of placing a drop of centrifuged The terminology and methods of reporting may differ slightly
urine on a glass slide, adding a cover slip, and examining mi­ among laboratories but must be consistent within a particular
croscopically has been substantially improved through the laboratory system. Routinely, casts are reported as the average
use of commercial slide systems.4 The CLSI recommends number per low-power field (lpf) following examination of
their use together with standardization of all phases of the 10 fields, and RBCs and WBCs, as the average number per
methodology, including the conventional method, as dis­ 10 high-power fields (hpf). Epithelial cells, crystals, and other
cussed in the following sections. Systems currently available elements are frequently reported in semiquantitative terms
include KOVA (Hycor Biomedical, Inc., Garden Grove, CA), such as, rare, few, moderate, and many, or as 1+, 2+, 3+, and 4+,
102 Part Two | Urinalysis

following laboratory format as to Ipf or hpf use. Laboratories

HISTORICAL NOTE
must also determine their particular reference values based on
the sediment
nverting the average numberfactor
concentration in use. For
of elements per lpf or hpf Urisys-
example,
Addis Count
tem, with a concentration factor of 30, states a reference
to the number per milliliter provides standardizationong value
for WBCs of per
the various techniques in use. Steps include the following: ­
zero to eight hpf, as opposed to the conven
The first procedure to standardize the quantitation of
tional value of zero to five per hpf used with a concentration
formed elements in the urine microscopic analysis was de­
factor of 12.
veloped by Addis in 1926. The Addis count, as it is called,
used a hemocytometer to count the number of RBCs,
WBCs, casts, and epithelial cells present in a 12-hour
specimen. Normal values have a wide range and are ap­
proximately 0 to 500,000 RBCs, 0 to 1,800,000 WBCs
EXAMPLE and epithelial cells, and 0 to 5000 hyaline casts.5 The
Addis count, which was used primarily to monitor the
1. Calculating the area of an lpf or hpf for the microscope in
course of diagnosed cases of renal disease, has been re­
use using the manufacturer-suppli field of view
placed by various standardized commercial systems for
diameter and the fo ula nr2 = rea.
the preparation, examination, and quantitation of formed
Diameter of hpf 0.35 mm elements in nontimed specimens.
3.14 x 0.17 0.096 mm2

2. Calculating the maxim umber of Ipfs or hpfs in the

viewing area. Table 6-2 Routine Urinalysis Correlations

Area under a 22 x 22 mm cover slip = 484 mm2 Microscopic

484 Elements Physical Chemical Exceptions
= 5040 fs
.096
RBCs Turbidity + Blood Number
3. Calculating the number of hpfs per milliliter of urine Red color + Protein Hemolysis
tested using the concentration factor and the volume WBCs Turbidity + Protein Number
of sediment examined.
+ Nitrite Lysis
5040 5040 + LE
------------ =----- = 21,000 hpf/mL of urine
.02 mL x 12 .24 Epithelial Turbidity Number
cells
4. Calculating the number of formed elements per milliliter
of urine by multiplying the number of hpfs per milliliter Casts + Protein Number
by the average number of formed elements per field. Bacteria Turbidity T pH Number
and type
4 WBC/hpf x 21,000 = 84,000 WBC/mL
+ Nitrite
+ Leukocytes
Crystals Turbidity pH Number
Provided the same microscope and volume of sediment
and type
examined are used, the number of lpfs and hpfs per milliliter
of urine remains the same, thereby simplifying the calculation. Color + Bilirubin
Laboratories should evaluate the advantages and disad­
vantages of adding an additional calculation step to the micro­
scopic examination. The CLSI states that all decisions with considered, as must the possibility of interference with chem­
regard to reporting of the microscopic should be based on the ical tests and the age of the specimen.
needs of the individual laboratory. Procedures should be com­
pletely documented and followed by all personnel.3
Sediment Examination
Correlating Results
Techniques
Microscopic results should be correlated with the physical and
chemical findings to ensure the accuracy of the report. Speci­ Many factors can influence the appearance of the urinary sed­
mens in which the results do not correlate must be rechecked iment, including cells and casts in various stages of develop­
for both technical and clerical errors. Table 6-2 shows some ment and degeneration, distortion of cells and crystals by the
of the more common correlations in the urinalysis; however, chemical content of the specimen, the presence of inclusions
the amount of formed elements or chemicals must also be in cells and casts, and contamination by artifacts. Therefore,
 Chapter 6 | Microscopic Examination of Urine 103

identification can sometimes be difficult even for experienced safranin O.6 The stain is available commercially under a variety
laboratory personnel. Identification can be enhanced through of names, including Sedi-Stain (Becton, Dickinson, Parsippany,
the use of sediment stains (Table 6-3) and different types of NJ) and KOVA stain (Hycor Biomedical, Inc., Garden Grove,
microscopy. CA). Commercial brands contain stabilizing chemicals to pre­
vent the precipitation that occurred with the original stain. The
Sediment Stains dye is absorbed well by WBCs, epithelial cells, and casts, pro­
Staining increases the overall visibility of sediment elements viding clearer delineation of structure and contrasting colors
being examined using bright-field microscopy by changing of the nucleus and cytoplasm. Table 6-4 provides an example
their refractive index. As mentioned, elements such as hyaline of the staining reactions as shown in the product literature.
casts have a refractive index very similar to that of urine. Stain­ A 0.5% solution of toluidine blue, a metachromatic stain,
ing also imparts identifying characteristics to cellular struc­ provides enhancement of nuclear detail. It can be useful in the
tures, such as the nuclei, cytoplasm, and inclusions. differentiation between WBCs and renal tubular epithelial cells
The most frequently used stain in urinalysis is the and is also used in the examination of cells from other body
Sternheimer-Malbin stain, which consists of crystal violet and fluids.

Table 6-3 Urine Sediment Stain Characteristics

Stain Action Function

Sternheimer-Mal Delineates structure and contrasting colors of Identifies WBCs, epitheli cells, and casts
cleus and cytoplasm
Toluidine blue Enhances nuc r detail Di tiates WBCs and renal tubular
epithelial (RTE) cells
2% acetic acid Lyses RBCs and enhances clei Distinguishes RBCs from WBCs, yeast, oil
droplets, and crystals
Lipid stains: Oil Red Stain tri erides and neutral fats ora -red Identify free fat droplets and lipid-containing
O and Sudan III not stain cholesterol cells and casts
Gram stain Differentiates gram-positive and gram-negative Identi terial casts
bacteria
ansel stain Methylene blue and eosin Y stains eosinophilic Identifies urinary eosinophi
granules
Prussian blue stain Stains structures containing iron Identifies yellow-brown granules of hemo­
siderin in cells and casts

Table 6-4 Expected Staining Reactions of Urine Sediment Constituents

Elements in Urinary Usual Distinguishing Color

Sediment of Stained Elements Comments

RBCs Neutral—pink to purple

Acid—pink (unstainei
Alkaline—purple
Nuclei Cytoplasm

WBCs (dark-staining cells) Purple Purple granules

Glitter cells (Sternheimer- Colorless or light blue Pale blue or Some glitter cells exhibit
Malbin positive cells) gray brownian movement
Renal tubular epithelial Dark shade of blue-purple Light shade of
cells blue-purple
Bladder tubular epithelial Blue-purple Light purple
cells

Continued
110 Part Two | Urinalysis

and imaged by the detector (Fig. 6-7). The fluorescent sub­ urine sediment constituents. To put this in better perspective,
stance can be observed in the fluorescent microscope as a the urine sediment constituents are now discussed individually
bright object against a dark background with high contrast with reference to the accompanying figures.
when ultraviolet light source is used. Powerful light sources
are required and are usually either mercury or xenon arc Red Blood Cells
lamps.9 In the urine, RBCs appear as smooth, non-nucleated, biconcave
disks measuring approximately 7 mm in diameter (Fig. 6-8).
They must be identified using high-power (40x) objective
Urine Sediment Constituents (x400 magnification). RBCs are routinely reported as the aver­
The normal urine sediment may contain a variety of formed age number seen in 10 hpfs.
elements. Even the appearance of small numbers of the usually In concentrated (hypersthenuric) urine, the cells shrink
pathologically significant RBCs, WBCs, and casts can be nor­ due to loss of water and may appear crenated or irregularly
mal. Likewise, many routine urine specimens contain nothing shaped (Fig. 6-9). In dilute (hyposthenuria) urine, the cells
more than a rare epithelial cell or mucous strand. Students absorb water, swell, and lyse rapidly, releasing their hemoglo­
often have difficulty adjusting to this, because in the classroom bin and leaving only the cell membrane. These large empty
setting, urine sediments containing abnormalities and multiple cells are called ghost cells and can be easily missed if speci­
elements are usually stressed. They must learn to trust their mens are not examined under reduced light.
observations after looking at the recommended number of Of all the urine sediment elements, RBCs are the most dif­
fields. Cellular elements are also easily distorted by the widely ficult for students to recognize. The reasons for this include
varying concentrations, pH, and presence of metabolites in RBCs’ lack of characteristic structures, variations in size, and
urine, making identification more difficult. close resemblance to other urine sediment constituents. RBCs
Actual normal numerical values are not clearly defined. As are frequently confused with yeast cells, oil droplets, and air
discussed previously, urine sediment preparation methods bubbles. Yeast cells usually exhibit budding (Fig. 6-10). Oil
determine the actual concentration of the sediment and, there­ droplets and air bubbles are highly refractile when the fine
fore, the number of elements that may be present in a micro­
scopic field. Commonly listed values include zero to two or
three RBCs per hpf, zero to five to eight WBCs per hpf, and
zero to two hyaline casts per lpf. Even these figures must be
taken in context with other factors, such as recent stress and
exercise, menstrual contamination, and the presence of other

Ocular

Barrier filter

Objective
Figure 6-8 Normal RBCs (x400).
Specimen
Condenser

Mercury lamp Collector

Incoming Deflecting mirror

Excitation filter
light waves
Cd Ultraviolet light
□ Visible light
Figure 6-7 Fluorescent microscopy. Figure 6-9 Microcytic and crenated RBCs (x100).
 Chapter 6 | Microscopic Examination of Urine 111

RBCs, leaving the yeast, oil droplets, and WBCs intact. Supra­
vital staining may also be helpful.
Studies have focused on the morphology of urinary RBCs
as an aid in determining the site of renal bleeding. RBCs that
vary in size, have cellular protrusions, or are fragmented are
termed dysmorphic (Fig. 6-13) and have been associated pri­
marily with glomerular bleeding. The number and appearance
of the dysmorphic cells must also be considered, because ab­
normal urine concentration affects RBC appearance, and small
numbers of dysmorphic cells are found with nonglomerular
hematuria.10,11 Dysmorphic RBCs also have been demonstrated
after strenuous exercise, indicating a glomerular origin of this
phenomenon.12 The dysmorphic cell most closely associated
with glomerular bleeding appears to be the acanthocyte with
Figure 6-10 Yeast. The presence of budding forms aid in distinguish­ multiple protrusions, which may be difficult to observe under
ing from RBCs (x400). bright-field microscopy13,14 Further analysis of sediments con­
taining dysmorphic RBCs using Wright’s stained preparations
adjustment is focused up and down (Fig. 6-11); they may also shows the cells to be hypochromic and better delineates the
appear in a different plane than other sediment constituents presence of cellular blebs and protrusions.
(Fig. 6-12). The rough appearance of crenated RBCs may re­
semble the granules seen in WBCs, but they are much smaller Clinical Significance
than WBCs. Should the identification continue to be doubtful, The presence of RBCs in the urine is associated with damage
adding acetic acid to a portion of the sediment will lyse the to the glomerular membrane or vascular injury within the
genitourinary tract. The number of cells present is indicative
of the extent of the damage or injury Patient histories often
mention the presence of macroscopic versus microscopic
hematuria.
When macroscopic hematuria is present, the urine ap­
pears cloudy with a red to brown color. Microscopic analysis
may be reported in terms of greater than 100 per hpf or as
specified by laboratory protocol. Macroscopic hematuria is fre­
quently associated with advanced glomerular damage but is
also seen with damage to the vascular integrity of the urinary
tract caused by trauma, acute infection or inflammation, and
coagulation disorders.
The observation of microscopic hematuria can be critical
to the early diagnosis of glomerular disorders and malignancy
of the urinary tract and to confirm the presence of renal calculi.
Figure 6-11 KOVA-stained squamous epithelial cells and oil droplets The presence of not only RBCs but also hyaline, granular, and
(x400). Notice how the oil droplet (arrow) resembles an RBC.

Figure 6-12 Air bubble. Notice no formed elements are in focus Figure 6-13 Dysmorphic RBCs (x400). Notice the smaller size and
(X100). fragmentation.
112 Part Two | Urinalysis

RBC casts may be seen following strenuous exercise. These

abnormalities are nonpathologic and disappear after rest.15 The
possibility of menstrual contamination must also be considered
in specimens from female patients.
As discussed previously, the presence or absence of RBCs
in the urine sediment cannot always be correlated with speci­
men color or a positive chemical test result for blood. The pres­
ence of hemoglobin that has been filtered by the glomerulus
produces a red urine with a positive chemical test result for
blood in the absence of microscopic hematuria. Likewise, a
specimen appearing macroscopically normal may contain
a small but pathologically significant number of RBCs when
examined microscopically.

White Blood Cells

WBCs are larger than RBCs, measuring an average of about
12 mm in diameter (Fig. 6-14).
The predominant WBC found in the urine sediment is
the neutrophil. Neutrophils are much easier to identify than
RBCs because they contain granules and multilobed nuclei
(Fig. 6-15 A and B). However, they are still identified using
high-power microscopy and are also reported as the average

SUMMARY 6-1 Microscopic RBCs

Appearance: Non-nucleated biconcave disks

Crenated in hypertonic urine
Ghost cells in hypotonic urine
Dysmorphic with glomerular
membrane damage Figure 6-15 WBCs. A.One segmented and one nonsegmented WBC
(x400). B. Notice the multilobed nucleoli (x400).
Sources of Yeast cells
identification Oil droplets
error: number seen in 10 hpfs. Neutrophils lyse rapidly in dilute
Air bubbles alkaline urine and begin to lose nuclear detail.
Reporting: Average number per 10 hpfs Neutrophils exposed to hypotonic urine absorb water and
Complete urinalysis Color swell. Brownian movement of the granules within these larger
correlations: cells produces a sparkling appearance, and they are referred to
Reagent strip blood reaction
as “glitter cells.” When stained with Sternheimer-Malbin stain,
these large cells stain light blue as opposed to the violet color
usually seen with neutrophils. Glitter cells are of no pathologic
significance (Fig. 6-16).

Eosinophils

The presence of urinary eosinophils is primarily associated

with drug-induced interstitial nephritis. Small numbers of
eosinophils may be seen with urinary tract infcion(UTI) and
renal transplant rejection. Evaluationafg^oBcentrated, stained
urine sediment is required fornjjjoiming a urinary eosinophil
test. Urine sediment may be concentrated by routine centrifu­
gation alone or with cytocentrifugation. The preferred
eosinophil stajd|l^ansel (Fig. 6-17); however, Wright’s stain
can alsobgOsed. The percentage of eosinophils in 100 to 500
cells is determined. Eosinophils are not normally seen in the
Figure 6-14 RBCs and one WBC (x400). Notice the larger size and ui.^e; therefore, the finding of more than 1% eosinophils is
granules in the WBC. considered significant.16
 Chapter 6 | Microscopic Examination of Urine 113

Figure 6-18 WBCs with acetic acid nuclear enhancement. Notice the
ameboid shape in some of the WBCs.

Figure 6-16 Glitter cells (x400). Observe the very noticeable Usually, fewer than five leukocytes per hpf are found in
granules. normal urine; however, higher numbers may be present in
urine from females. Although leukocytes, like RBCs, may enter
the urine through glomerular or capillary trauma, they are also
capable of ameboid migration through the tissues to sites of
infection or inflammation. An increase in urinary WBCs is
called pyuria and indicates the presence of an infection or
inflammation in the genitourinary system. Bacterial infections,
including pyelonephritis, cystitis, prostatitis, and urethritis,
are frequent causes of pyuria. However, pyuria is also present
in nonbacterial disorders, such as glomerulonephritis, lupus
erythematosus, interstitial nephritis, and tumors. Reporting
the presence of bacteria in specimens containing leukocytes
is important.

Epithelial Cells
It is not unusual to find epithelial cells in the urine, because
Figure 6-17 Hansel-stained eosinophils (x400).
they are derived from the linings of the genitourinary system.
Unless they are present in large numbers or in abnormal forms,
Mononuclear Cells

Lyn'hocytes, monocytes, macrophages, and histiocytes may

be pWnt in small numbers and are usually not identified in
SUMMARY 6-2 Microscopic WBCs
the wet^bgparation urine microscopic analysis. Because lym—
Appearance: Larger than RBCs
phocytes'ai^he smallest WBCs, they may resemble RBCs.
They may be^||nin increased numbers in the early stjg|s of Granulated, multilobed neutrophils
renal transplant rS|lh|ion. Monocytes, macrophagcs^ncl his­ Glitter cells in hypotonic urine
tiocytes are large cdl^hd^may appear vacuolatgO^ contain Mononuclear cells with abundant
inclusions. Specimens coBaining an increg^l^ amount of cytoplasm
mononuclear cells that cannot be identified as epithelial cells
Sources of Renal tubular epithelial cells
should be referred for cytodiagnostic urine testing.
identification
The primary concern in the identification of WBCs is the
error:
differentiation of mononuclear cells and disintegrating neu­
trophils from round renaJid0Bular epithelialfcJE) cells. RTE Reporting: Average number per 10 hpfs
cells are usually larger than WBCs with an eccentrically
Complete Leukocyte esterase
located nucleus. WBCs in the process of ameboid motion
urinalysis Nitrite
may be difficult to distinguish from epithelial cells because
correlations:
of their irregular shape. Supravital staining or the addition of Specific gravity
adlBBcid can be used to enhance nuclear detail (Fig. 6-18), pH
if necessary.
114 Part Two | Urinalysis

they represent normal sloughing of old cells. Three types of

epithelial cells are seen in urine: squamous, transitional
(urothelial), and renal tubular (Fig. 6-19). They are classified
according to their site of origin within the genitourinary
system.

Squamous Epithelial Cells

Squamous cells are the largest cells found in the urine sediment.
They contain abundant, irregular cytoplasm and a prominent
nucleus about the size of an RBC (Fig. 6-20 A and B). They
are often the first structures observed when the urine sediment
is examined under low-power magnification. Usually at least a
few squamous epithelial cells are present in the urine sediment
and can serve as a good reference for focusing of the micro­
scope. After examination of the appropriate number of fields,
squamous epithelial cells are commonly reported in terms of
rare, few, moderate, or many They are reported in terms of
low-power or high-power magnification based on laboratory
protocol.
Difficulty identifying squamous cells is rare. However, they
may occasionally appear folded, possibly resembling a cast,
and will begin to disintegrate in urine that is not fresh. In urine
sediments containing large amounts of squamous cells, clumps
of cells may make it more difficult to enumerate smaller patho­
logic elements, such as RBCs and WBCs, and they should be
carefully examined (Figs. 6-21, 6-22, and 6-23).
Squamous epithelial cells originate from the linings of the B
vagina and female urethra and the lower portion of the male Figure 6-20 A. Squamous epithelial cells identifiable under low
urethra. They represent normal cellular sloughing and have no power (x100). B. KOVA-stained squamous epithelial cells (x400). Com­
pathologic significance. Increased amounts are more frequently pare the size of the nucleus with the RBCs in Figure 6-8.
seen in urine from female patients. Specimens collected using
the midstream clean-catch technique contain less squamous
cell contamination.
A variation of the squamous epithelial cell is the clue cell,
which does have pathologic significance. Clue cells are indica­
tive of vaginal infection by the bacterium Gardnerella vaginalis.
They appear as squamous epithelial cells covered with the
Gardnerella coccobacillus. To be considered a clue cell, the
bacteria should cover most of the cell surface and extend

Figure 6-21 Phenazopyridine-stained sediment showing squamous

epithelial cells and phenazopyridine crystals formed following refrig­
eration (x400).

beyond the edges of the cell. This gives the cell a granular, ir­
regular appearance. Routine testing for clue cells is performed
by examining a vaginal wet preparation for the presence of the
characteristic cells (see Chapter 15). However, small numbers
of clue cells may be present in the urinary sediment. Micro­
Figure 6-19 Sediment-containing squamous, caudate transitional, scopists should remain alert for their presence, as urinalysis
and RTE cells (x400). may be the first test performed on the patient.
 Chapter 6 | Microscopic Examination of Urine 115

Figure 6-22 Clump of squamous epithelial cells (x400). Figure 6-24 Transitional epithelial cells.

Figure 6-25 KOVA-stained spherical transitional epithelial cells

Figure 6-23 Clump of squamous epithelial cells with folded forms (x400).
(x400).

Transitional Epithelial (Urothelial) Cells

Transitional epithelial cells are smaller than squamous cells and

appear in several forms, including spherical, polyhedral, and
caudate (Figs. 6-24, 6-25, and 6-26). These differences are
caused by the ability of transitional epithelial cells to absorb
large amounts of water. Cells in direct contact with the urine
absorb water, becoming spherical in form and much larger
than the polyhedral and caudate cells. All forms have distinct,
centrally located nuclei. Transitional cells are identified and
enumerated using high-power magnification. Like squamous
cells, they are usually reported as rare, few, moderate, or many
following laboratory protocol.
Figure 6-26 Caudate transitional epithelial cells (x400).
Spherical forms of transitional epithelial cells are some­
times difficult to distinguish from RTE cells. The presence of a
centrally located rather than eccentrically placed nucleus, and numbers in normal urine, representing normal cellular slough­
supravital staining, can aid in the differentiation. ing. Increased numbers of transitional cells seen singly, in pairs,
Transitional epithelial cells originate from the lining of the or in clumps (syncytia) are present following invasive urologic
renal pelvis, calyces, ureters, and bladder, and from the upper procedures such as catheterization and are of no clinical signif­
portion of the male urethra. They are usually present in small icance (Fig. 6-27). An increase in transitional cells exhibiting
116 Part Two | Urinalysis

Figure 6-27 Syncytia of transitional epithelial cells from catheterized Figure 6-29 RTE cells. Oval distal convoluted tubule cells. Notice the
specimen (x400). eccentrically placed nuclei (x400).

abnormal morphology such as vacuoles and irregular nuclei spherical and polyhedral transitional cells (Fig. 6-30). Be­
may be indicative of malignancy or viral infection. In such cases, cause RTE cells are often present as a result of tissue destruc­
the specimen should be referred to the pathologist. tion (necrosis), the nucleus is not easily visible in unstained
sediment.
Renal Tubular Epithelial Cells Cells from the collecting duct that appear in groups of
three or more are called renal fragments. They are frequently
RTE cells vary in size and shape depending on the area of the
seen as large sheets of cells. PCT and DCT cells are not seen in
renal tubules from which they originate. The cells from the prox­
large sheets of cells (Fig. 6-31).
imal convoluted tubule (PCT) are larger than other RTE cells.
They tend to have a rectangular shape and are referred to as
columnar or convoluted cells. The cytoplasm is coarsely granular,
and the RTE cells often resemble casts. They should be closely
examined for the presence of a nucleus, as a nucleus would
not be present in a cast. Notice the nucleus and granules in
Figure 6-28. This is a PCT. This is fine cell that has absorbed fat
globules and could easily be mistaken for a granular or fatty cast.
Cells from the distal convoluted tubule (DCT) are smaller
than those from the PCT and are round or oval. They can be
mistaken for WBCs and spherical transitional epithelial cells.
Observation of the eccentrically placed round nucleus aids in
differentiating them from spherical transitional cells (Fig. 6-29).
Collecting duct RTE cells are cuboidal and are never
round. Along with the eccentrically placed nucleus, the pres­
ence of at least one straight edge differentiates them from Figure 6-30 RTE cells, cuboidal from the collecting duct (x400).

Figure 6-28 RTE cell. Columnar proximal convoluted tubule cell with Figure 6-31 Fragment of RTE cells from the collecting duct under
granules and attached fat globules (x400). N, nucleus. phase microscopy (x400).
 Chapter 6 | Microscopic Examination of Urine 117

RTE cells must be identified and enumerated using Oval Fat Bodies
high-power magnification. Depending on laboratory proto­
RTE cells absorb lipids that are present in the glomerular fil­
col, they may be reported as rare, few, moderate, or many,
trate. They then appear highly refractile, and the nucleus may
or as the actual number per high-power field. Classification
be more difficult to observe. These lipid-containing RTE cells
of RTE cells as to site of origin is not considered a part of
are called oval fat bodies (Fig. 6-33). They are usually seen in
the routine sediment analysis and often requires special
conjunction with free-floating fat droplets.
staining techniques. The presence of more than two RTE
Identification of oval fat bodies is confirmed by staining
cells per high-power field indicates tubular injury, and
the urine sediment with Sudan III or Oil Red O fat stains and
such specimens should be referred for cytologic urine
examining the sediment using polarized microscopy^ne
testing.17
droplets are composed of triglycerides, neutral fats, and cho­
lesterol. Fat stains stain triglycerides and neutral fats, produc­
Clinical Significance
ing orange-red droplets (Fig. 6-34). Examination^fnhe urine
RTE cells are the most clinically significant of the epithelial
sediment using polarized light results in the appearance of
cells. The presence of increased amounts is indicative of necro­
characteristic Maltese cross formations in drofllets containing
sis of the renal tubules, with the possibility of affecting overall
cholesterol (Fig. 6-35). Urine sedimentsoigative for fat after
renal function.
staining should still be checked usirm^oarizccl light in case
Conditions producing tubular necrosis include exposure
only cholesterol is present. l.ikcwLogJ^taining should be per­
to heavy metals, drug-induced toxicity, hemoglobin and myo­
formed on urine sediments negative under polarized light.
globin toxicity, viral infections (hepatitis B), pyelonephritis, al­
Oval fat bodies are reported as the average number per hpf.
lergic reactions, malignant infiltrations, salicylate poisoning,
Free-floating fat droplets also stain or polarize depend­
and acute allogenic transplant rejection. RTE cells may also be
ing on their composition. They may be observed floating on
seen as secondary effects of glomerular disorders. Renal frag­
the top of the specimen. Care should be taken not to confuse
ments are an indication of severe tubular injury with basement
the droplets with starch and crystal particles that also polar­
membrane disruption. Single cuboidal cells are particularly no­
ize. Specimen contamination by vaginal preparations and
ticeable in cases of salicylate poisoning.
Because one of the functions of RTE cells is reabsorption
of the glomerular filtrate, it is not unusual for them to contain
substances from the filtrate. RTE cells absorb bilirubin present
in the filtrate as the result of liver damage, such as occurs with
viral hepatitis, and appear a deep yellow color. As discussed
in Chapter 5, hemoglobin present in the filtrate is absorbed
by the RTE cells and converted to hemosiderin. Therefore, fol­
lowing episodes of hemoglobinuria (transfusion reactions,
paroxysmal nocturnal hemoglobinuria, etc.), the RTE cells
may contain the characteristic yellow-brown hemosiderin
granules. The granules may also be seen free-floating in the
urine sediment. Confirmation of the presence of hemosiderin
is performed by staining the urine sediment with Prussian
blue. The iron-containing hemosiderin granules stain blue
(Fig. 6-32).
Figure 6-33 Oval fat body (x400).

Figure 6-32 Prussian blue-stained hemosiderin granules. Figure 6-34 Sudan III-stained oval fat body (x400).
118 Part Two | Urinalysis

SUMMARY 6-3 Epithelial Cells

Squamous Cells
Appearance: Largest cells in the sediment
with abundant, irregular
cytoplasm and prominent
nuclei
Sources of error: Rarely encountered, folded cells
may resemble casts
Reporting: Rare, few, moderate, or many
per lpf
Complete urinalysis Clarity
Figure 6-35 Oval fat body under bright-field (left) and polarized correlations:
(right) microscopy. Notice the Maltese cross formation (arrow) Transitional Cells
(x400).
Appearance: Spherical, polyhedral, or cau­
date with centrally located
nucleus
lubljcants used in specimen collection must be considgjjft
when^^by free-floating fat droplets are present. Sources of error: Spherical forms resemble RTE
LipidUjjais most frequently associated with da«|ge to the cells
glomerulusclU|gd by the nephrotic syndromefj||^hapter 7). Reporting: Rare, few, moderate, or many per
It is also seen Wnhhgyere tubular necrosis,dlbetes mellitus, hpf
and in trauma cases that cause release of bone marrow fat from Complete urinalysis Clarity
the long bones. In lipid-storage diseases, large fat-laden histi­ correlations: Blood, if malignancy-
ocytes may also be present^jliy^^^e differentiated from
associated
oval fat bodies by their largPBize.
In cases of acuteJjubular necrosis, ^0®!!^ containing RTE Cells
large, nonlipid-filled vacuoles may be seen along with normal Appearance: Rectangular, columnar, round,
renal tubulaj^|||jmnd oval fat bodies. Referred to a^lbub^le oval or, cuboidal with an eccen­
cd ls^gj^J^mppcar to represent injured cells in whicn^h; tric nucleus possibly bilirubin-
gjdlplasmic reticulum has dilated prior to cell death.18 stained or hemosiderin-laden
Sources of error: Spherical transitional cells
Bacteria
Granular casts
Bacteria are not normally present in urine. However, unless
Reporting: Average number per 10 hpfs
specimens are collected under sterile conditions (catheteriza­
tion), a few bacteria are usually present as a result of vaginal, Complete urinalysis Leukocyte esterase and nitrite
urethral, external genitalia, or collection-container contamina­ correlations: (pyelonephritis)
tion. These contaminant bacteria multiply rapidly in specimens Color
that remain at room temperature for extended periods, but are Clarity
of no clinical significance. They may produce a positive nitrite
Protein
test result and also frequently result in a pH above 8, indicating
an unacceptable specimen. Bilirubin (hepatitis)
Bacteria may be present in the form of cocci (spherical) Blood
or bacilli (rods). Owing to their small size, they must be ob­ Oval Fat Bodies
served and reported using high-power magnification. They
Appearance: Highly refractile RTE cells
are reported as few, moderate, or many per high-power field.
To be considered significant for UTI, bacteria should be ac­ Sources of error: Confirm with fat stains and
companied by WBCs. Some laboratories report bacteria only polarized microscopy
when observed in fresh specimens in conjunction with WBCs Reporting: Average number per hpf
(Fig. 6-36 A and B). The presence of motile organisms in a Complete urinalysis Clarity
drop of fresh urine collected under sterile conditions corre­ correlations: Blood
lates well with a positive urine culture. Observing bacteria for
motility also is useful in differentiating them from similarly Protein
appearing amorphous phosphates and urates. The use of Free fat droplets/fatty casts
phase microscopy aids in the visualization of bacteria.
 Chapter 6 | Microscopic Examination of Urine 119

Figure 6-36 A. Rod-shaped bacteria often seen in urinary tract in­ Figure 6-37 A. Budding yeast B. Yeast showing mycelial forms
fections. B. KOVA-stained bacteria and WBC (x400). (x400).

The presence of bacteria can be indicative of either lower the growth of yeast. As with bacteria, a small amount of yeast
or upper UTI. Specimens containing increased bacteria and entering a specimen as a contaminant multiplies rapidly if the
leukocytes are routinely followed up with a specimen for quan­ specimen is not examined while fresh. A true yeast infection
titative urine culture. The bacteria most frequently associated should be accompanied by the presence of WBCs.
with UTI are the Enterobacteriaceae (referred to as gram­
negative rods); however, the cocci-shaped Staphylococcus and Parasites
Enterococcus are also capable of causing UTI. The actual bacte­ The most frequent parasite encountered in the urine is
ria producing an UTI cannot be identified with the microscopic Trichomonas vaginalis. The Trichomonas trophozoite is a pear­
examination. shaped flagellate with an undulating membrane. It is easily
identified in wet preparations of the urine sediment by its rapid
Yeast
darting movement in the microscopic field. Trichomonas is usu­
Yeast cells appear in the urine as small, refractile oval structures ally reported as rare, few, moderate, or many per hpf.
that may or may not contain a bud. In severe infections, they When not moving, Trichomonas is more difficult to identify
may appear as branched, mycelial forms (Fig. 6-37 A and B). and may resemble a WBC, transitional, or RTE cell. Use of
Yeast cells are reported as rare, few, moderate, or many per hpf. phase microscopy may enhance visualization of the flagella or
Differentiation between yeast cells and RBCs can some­ undulating membrane.
times be difficult. Careful observation for budding yeast cells T. vaginalis is a sexually transmitted pathogen associated
should be helpful, as shown in Figure 6-10. primarily with vaginal inflammation. Infection of the male
Yeast cells, primarily Candida albicans, are seen in the urine urethra and prostate is asymptomatic. Males are often asymp­
of diabetic patients, immunocompromised patients, and tomatic carriers (Fig. 6-38).
women with vaginal moniliasis. The acidic, glucose-containing The ova of the bladder parasite Schistosoma haematobium
urine of patients with diabetes provides an ideal medium for will appear in the urine. However, this parasite is seldom seen
120 Part Two | Urinalysis

Figure 6-38 Trichomonas vaginalis. Notice the flagella and undulat­

ing membrane. (From Leventhal and Cheadle, Ed 6, p 87).

in the United States. It has been associated with bladder

cancer in other countries (Fig. 6-39). Fecal contamination of
a urine specimen can also result in the presence of ova from
intestinal parasites in the urine sediment. The most common
contaminant is ova from the pinworm Enterobius vermicularis
(Fig. 6-40 A and B).

Spermatozoa
Spermatozoa are easily identified in the urine sediment by
their oval, slightly tapered heads and long, flagella-like tails
(Fig. 6-41). Urine is toxic to spermatozoa; therefore, they
rarely exhibit the motility observed when examining a semen
specimen. Figure 6-40 A. Enterobius vermicularis ova (x100) B. Enterobius ver­
Spermatozoa are occasionally found in the urine of both micularis ova (x400).
men and women following sexual intercourse, masturbation,
or nocturnal emission. They are rarely of clinical significance
except in cases of male infertility or retrograde ejaculation in
which sperm is expelled into the bladder instead of the urethra.
A positive reagent strip test for protein may be seen when in­
creased amounts of semen are present.
Laboratory protocols vary with regard to reporting or
not reporting the presence of spermatozoa in a urine speci­
men. Laboratories not reporting its presence cite the lack of
clinical significance and possible legal consequences. Labo­
ratories supporting the reporting of spermatozoa cite the
possible clinical significance and the minimal possibility of
legal consequences.19

Figure 6-41 Spermatozoa (x400).

Mucus
Mucus is a protein material produced by the glands and ep­
ithelial cells of the lower genitourinary tract and the RTE cells.
Immunologic analysis has shown that uromodulin is a major
constituent of mucus. Uromodulin is a glycoprotein excreted
by the RTE cells of the distal convoluted tubules and upper
collecting ducts.
Mucus appears microscopically as thread-like structures
with a low refractive index. Subdued light is required when
Figure 6-39 Schistosoma haematobium ova (x300). Eggs are often using bright-field microscopy Care must be taken not to con­
contained in the last few drops of urine expelled from the bladder. fuse clumps of mucus with hyaline casts. The differentiation
 Chapter 6 | Microscopic Examination of Urine 121

can usually be made by observing the irregular appearance of

SUMMARY 6-4 Miscellaneous Structures
the mucous threads (Fig. 6-42 A and B).
Mucus threads are reported as rare, few, moderate, or
Bacteria
many per lpf.
Appearance: Small spherical and rod-shaped
Mucus is more frequently present in female urine speci­
mens. It has no clinical significance when present in either structures
female or male urine. Sources of error: Amorphous phosphates and
urates
Casts Reporting: Few, moderate, or many per hpf,
Casts are the only elements found in the urinary sediment that the presence of WBCs may be
are unique to the kidney. They are formed within the lumens required
of the distal convoluted tubules and collecting ducts, providing Complete urinalysis pH
a microscopic view of conditions within the nephron. Their correlations: Nitrite
shape is representative of the tubular lumen, with parallel sides
and somewhat rounded ends, and they may contain additional LE
elements present in the filtrate. WBCs
Examination of the sediment for the detection of casts is Yeast
performed using lower power magnification. When the glass
Appearance: Small, oval, refractile structures
cover-slip method is used, low-power scanning should be per­
with buds and/or mycelia
formed along the edges of the cover slip. Observation under
subdued light is essential, because the cast matrix has a low Sources of error: RBCs
refractive index. Similar to many other sediment constituents, Reporting: Rare, few, moderate, or many per
hpf, the presence of WBCs may
be required
Complete urinalysis Glucose
correlations: LE
WBCs
Trichomonas
Appearance: Pear-shaped, motile, flagellated
Sources of error: WBCs, renal tubular epithelial cells
Reporting: Rare, few, moderate, or many per
hpf
Complete urinalysis LE
correlations: WBCs
Spermatozoa
Appearance: Tapered oval head with long,
thin tail
Sources of error: None
Reporting: Present, based on laboratory
protocol
Complete urinalysis Protein
correlations:
Mucus
Appearance: Single or clumped threads with a
low refractive index
Sources of error: Hyaline casts
Reporting: Rare, few, moderate, or many
per lpf
Complete urinalysis None
correlations:
Figure 6-42 A. Mucus threads (x400). B. Mucus clump (x400).
122 Part Two | Urinalysis

the cast matrix dissolves quickly in dilute, alkaline urine. Once clinical conditions and will be discussed separately in this
detected, casts must be further identified as to composition section.
using high-power magnification. They are reported as the
average number per 10 lpfs. Hyaline Casts

The most frequently seen cast is the hyaline type, which consists
Cast Composition and Formation
almost entirely of uromodulin. The presence of zero to two hya­
The major constituent of casts is uromodulin. Other proteins line casts per lpf is considered normal, as is the finding of
present in the urinary filtrate, such as albumin and im­ increased numbers following strenuous exercise, dehydration,
munoglobulins, are also incorporated into the cast matrix. heat exposure, and emotional stress.1 23456*15 Pathologically, hyaline
Under normal conditions, uromodulin is excreted at a rela­ casts are increased in acute glomerulonephritis, pyelonephritis,
tively constant rate. The rate of excretion appears to increase chronic renal disease, and congestive heart failure.
under conditions of stress and exercise, which may account Hyaline casts appear colorless in unstained sediments and
for the transient appearance of hyaline casts when these con­ have a refractive index similar to that of urine; thus, they can
ditions are present. The protein gels more readily under easily be overlooked if specimens are not examined under sub­
conditions of urine-flow stasis, acidity, and the presence of dued light (Figs. 6-43 and 6-44). Sternheimer-Malbin stain
sodium and calcium. The extent of protein glycosylation is produces a pink color in hyaline casts. Increased visualization
also important.20 Uromodulin protein is found in both normal can be obtained by phase microscopy (Fig. 6-45 A and B).
and abnormal urine and, as discussed previously, is a major The morphology of hyaline casts is varied, consisting of
constituent of mucus. It is not detected by reagent strip pro­ normal parallel sides and rounded ends, cylindroid forms, and
tein methods. Therefore, the increased urinary protein fre­ wrinkled or convoluted shapes that indicate aging of the cast
quently associated with the presence of casts is caused by matrix (Fig. 6-46). The presence of an occasional adhering cell
underlying renal conditions. or granule may also be observed (Fig. 6-47) but does not
Scanning electron microscope studies have provided a change the cast classification.
step-by-step analysis of the formation of the uromodulin pro­
tein matrix21:
1. Aggregation of uromodulin protein into individual pro­
tein fibrils attached to the RTE cells
2. Interweaving of protein fibrils to form a loose fibrillar
network (urinary constituents may become enmeshed
in the network at this time)
3. Further protein fibril interweaving to form a solid
structure
4. Possible attachment of urinary constituents to the solid
matrix
5. Detachment of protein fibrils from the epithelial cells
6. Excretion of the cast
As the cast forms, urinary flow within the tubule de­
creases as the lumen becomes blocked. The accompanying Figure 6-43 Hyaline casts under low power (x100).
dehydration of the protein fibrils and internal tension may
account for the wrinkled and convoluted appearance of older
hyaline casts.22 The width of the cast depends on the size of
the tubule in which it is formed. Broad casts may result from
tubular distension or, in the case of extreme urine stasis,
from formation in the collecting ducts. Formation of casts at
the junction of the ascending loop of Henle and the distal
convoluted tubule may produce structures with a tapered
end. These have been referred to as cylindroids, but they
have the same significance as casts. In fact, the presence of
urinary casts is termed cylindruria. The appearance of a cast
is also influenced by the materials present in the filtrate at
the time of its formation and the length of time it remains
in the tubule. Any elements present in the tubular filtrate,
including cells, bacteria, granules, pigments, and crystals,
may become embedded in or attached to the cast matrix. Figure 6-44 Hyaline cast (A) and amorphous urates (B) attached to
The types of casts found in the sediment represent different mucus pseudocast (x100).
 Chapter 6 | Microscopic Examination of Urine 123

Figure 6-47 Hyaline cast containing occasional granules (x400).

casts have also been observed in healthy individuals following

participation in strenuous contact sports.15
RBC casts are easily detected under low power by their
orange-red color. They are more fragile than other casts and
may exist as fragments or have a more irregular shape as the
result of tightly packed cells adhering to the protein matrix
(Figs. 6-48 and 6-49). Examination under high-power mag­
nification should concentrate on determining that a cast ma­
trix is present, thereby differentiating the structure from a

Figure 6-45 A. Hyaline cast (x400). B. Hyaline cast under phase

microscopy (x400).

Figure 6-48 RBC cast (x400).

Figure 6-46 Convoluted hyaline cast (x400).

RBC Casts

Whereas the finding of RBCs in the urine indicates bleeding

from an area within the genitourinary tract, the presence of
RBC casts is much more specific, showing bleeding within the
nephron. RBC casts are primarily associated with damage to
the glomerulus (glomerulonephritis) that allows passage of the
cells through the glomerular membrane; however, any damage
to the nephron capillary structure can cause their formation.
RBC casts associated with glomerular damage are usually Figure 6-49 KOVA-stained RBC cast under phase microscopy
associated with proteinuria and dysmorphic erythrocytes. RBC (x400).
124 Part Two | Urinalysis

clump of RBCs. Because of the serious diagnostic implications

of RBC casts, the actual presence of RBCs must also be verified
to prevent the inaccurate reporting of nonexistent RBC casts.
It is highly improbable that RBC casts will be present in the
absence of free-standing RBCs and a positive reagent strip test
for blood (Fig. 6-50).
As an RBC cast ages, cell lysis begins and the cast develops
a more homogenous appearance, but retains the characteristic
orange-red color from the released hemoglobin (Fig. 6-51).
These casts may be distinguished as blood casts, indicating
greater stasis of urine flow. However, because all casts contain­
ing blood have the same clinical significance, this is not con­
sidered necessary Both types of casts are reported as the
number of RBC casts per lpf.
In the presence of massive hemoglobinuria or myoglobin­ Figure 6-52 Granular, dirty, brown cast (x400).
uria, homogenous orange-red or red-brown casts may be ob­
served. Granular, dirty, brown casts representing hemoglobin WBC Casts
degradation products such as methemoglobin may also be
present (Fig. 6-52). They are associated with the acute tubular The appearance of WBC casts in the urine signifies infection
necrosis often caused by the toxic effects of massive hemoglo­ or inflammation within the nephron. They are most frequently
binuria that can lead to renal failure. These dirty, brown casts associated with pyelonephritis and are a primary marker for
must be present in conjunction with other pathologic findings distinguishing pyelonephritis (upper UTI) from cystitis (lower
such as RTE cells and a positive reagent strip test for blood. UTI). However, they are also present in nonbacterial inflam­
mations such as acute interstitial nephritis and may accompany
RBC casts in glomerulonephritis.
WBC casts are visible under low-power magnification but
must be positively identified using high power. Most frequently,
WBC casts are composed of neutrophils; therefore, they may
appear granular, and, unless disintegration has occurred, mul-
tilobed nuclei will be present (Fig. 6-53). Supravital staining
may be necessary to demonstrate the characteristic nuclei
(Fig. 6-54). It is particularly helpful for differentiating WBC
casts from RTE casts. Observation of free WBCs in the sediment
is also essential (Fig. 6-55). Bacteria are present in cases of
pyelonephritis, but are not present with acute interstitial nephri­
tis; however, eosinophil casts may be present in appropriately
stained specimens (Hansel and Wright’s stains).

Figure 6-50 Disintegrating RBC cast. Notice the presence of free

RBCs (arrows) to confirm identification.

Figure 6-51 Cast containing hemoglobin pigment. A comparison of

RBCs (A) and yeast (B) also can be made (x400). Figure 6-53 WBC cast. Notice the free WBCs to aid in identification.
 Chapter 6 | Microscopic Examination of Urine 125

Identification of bacterial casts can be difficult, because

packed casts packed with bacteria can resemble granular casts.
Their presence should be considered when WBC casts and
many free WBCs and bacteria are seen in the sediment. Con­
firmation of bacterial casts is best made by performing a Gram
stain on the dried or cytocentrifuged sediment.

Epithelial Cell Casts

Casts containing RTE cells represent the presence of advanced
tubular destruction, producing urinary stasis along with dis­
ruption of the tubular linings. Similar to RTE cells, they are
associated with heavy metal and chemical or drug-induced tox­
icity, viral infections, and allograft rejection. They also accom­
Figure 6-54 KOVA-stained WBC cast (x400). pany WBC casts in cases of pyelonephritis.
As discussed previously, the fibrils of uromodulin protein
that make up the cast matrix remain attached to the RTE cells
that produce them; therefore, the observation of an occasional
tubular cell attached to a hyaline cast can be expected. When
tubular damage is present, some cells may be incorporated
into the cast matrix, but the majority will be very noticeably
attached to the cast surface.
Owing to the formation of casts in the distal convoluted
tubule, the cells visible on the cast matrix are the smaller,
round, and oval cells (Fig. 6-57). They may be difficult to dif­
ferentiate from WBCs, particularly if degeneration has oc­
curred. Staining and the use of phase microscopy can be
helpful to enhance the nuclear detail needed for identification
(Figs. 6-58 A and B and 6-59). Fragments of epithelial tissue
may also be attached to the cast matrix. Bilirubin-stained RTE
Figure 6-55 Disintegrating WBC cast (x400). cells are seen in cases of hepatitis (see Fig. 6-59).

Fatty Casts
Casts tightly packed with WBCs may have irregular borders.
These structures should be carefully examined to determine that Fatty casts are seen in conjunction with oval fat bodies and
a cast matrix is present. WBCs frequently form clumps, and free fat droplets in disorders causing lipiduria. They are most
these do not have the same significance as casts (Fig. 6-56). frequently associated with the nephrotic syndrome, but are
also seen in toxic tubular necrosis, diabetes mellitus, and
Bacterial Casts crush injuries.
Fatty casts are highly refractile under bright-field mi­
Bacterial casts containing bacilli both within and bound to the
croscopy. The cast matrix may contain few or many fat
protein matrix are seen in pyelonephritis.23 They may be pure
droplets, and intact oval fat bodies may be attached to the
bacterial casts or mixed with WBCs.

Figure 6-56 WBC clump. Notice the absence of a cast matrix. Figure 6-57 RTE cell cast (x400).
126 Part Two | Urinalysis

Figure 6-60 Fatty cast showing adherence of fat droplets (arrows) to

cast matrix (x400).

Figure 6-58 A. KOVA-stained RTE cell cast (x400). B. KOVA-stained

RTE cell cast under phase microscopy (x400).

Figure 6-61 Fatty cast (x400).

Figure 6-59 RTE cast with bilirubin-stained cells (x400).

matrix (Figs. 6-60, 6-61, 6-62). Confirmation of fatty casts

Figure 6-62 Fatty cast under phase microscopy (x400).
is performed using polarized microscopy and Sudan III or Oil
Red O fat stains. As discussed previously, cholesterol demon­
strates characteristic Maltese cross formations under polarized encountered include RBC and WBC casts in glomeru­
light, and triglycerides and neutral fats stain orange with fat lonephritis and WBC and RTE cell casts, or WBC and bacte­
stains. Fats do not stain with Sternheimer-Malbin stains. rial casts in pyelonephritis.
The presence of mixed elements in a cast may make iden­
Mixed Cellular Casts
tification more difficult. Staining or phase microscopy aids in
Considering that a variety of cells may be present in the uri­ the identification. When mixed casts are present, there should
nary filtrate, observing casts containing multiple cell types also be homogenous casts of at least one of the cell types, and
is not uncommon. Mixed cellular casts most frequently they will be the primary diagnostic marker. For example, in
 Chapter 6 | Microscopic Examination of Urine 127

glomerulonephritis, the predominant casts will be RBC, and

in pyelonephritis, the predominant casts will be WBC. Bacteria
are often incorporated into WBC casts and provide little addi­
tional diagnostic significance. Laboratory protocol should be
followed in the reporting of mixed cellular casts.

Granular Casts

Coarsely and finely granular casts are frequently seen in the

urinary sediment and may be of pathologic or nonpathologic
significance. It is not considered necessary to distinguish be­
tween coarsely and finely granular casts.
The origin of the granules in nonpathologic conditions
appears to be from the lysosomes excreted by RTE cells dur­
ing normal metabolism.24 It is not unusual to see hyaline casts Figure 6-65 Granular disintegrating cellular cast (x400).
containing one or two of these granules. Increased cellular
metabolism occurring during periods of strenuous exercise ac­
counts for the transient increase of granular casts that accom­
pany the increased hyaline casts (Figs. 6-63 and 6-64).15 In
disease states, granules may represent disintegration of cellular
casts and tubule cells or protein aggregates filtered by the
glomerulus (Figs. 6-65 and 6-66). Scanning electron micro­
scope studies have confirmed that granular casts seen in con­
junction with WBC casts contain WBC granules of varying
sizes.25 Urinary stasis allowing the casts to remain in the

Figure 6-66 Coarsely granular cast (A), squamous epithelial cell (B),
and mucus (C) (x400).

tubules must be present for granules to result from disinte­

gration of cellular casts.
Granular casts occurring as a result of cellular disintegra­
tion may contain an occasional recognizable cell. Granular
casts are easily visualized under low-power microscopy How­
ever, final identification should be performed using high power
Figure 6-63 Finely granular cast (A) and uric acid crystals (B) (x400). to determine the presence of a cast matrix.
Artifacts, such as clumps of small crystals and fecal debris,
may occur in shapes resembling casts and must be differenti­
ated. As mentioned previously, columnar RTE cells may also
resemble granular casts, and staining for nuclear detail may be
required.
When granular casts remain in the tubules for extended
periods, the granules further disintegrate, and the cast matrix
develops a waxy appearance. The structure becomes more
rigid, the ends of the casts may appear jagged or broken, and
the diameter becomes broader (Fig. 6-67).

Waxy Casts

Waxy casts are representative of extreme urine stasis, indicating

chronic renal failure. They are usually seen in conjunction with
other types of casts associated with the condition that has
Figure 6-64 Granular cast formed at a tubular bend (x400). caused the renal failure.
128 Part Two | Urinalysis

Figure 6-67 Granular cast degenerating into waxy cast (x400). Figure 6-70 KOVA-stained waxy cast (x400).

The brittle, highly refractive cast matrix from which these

Broad Casts
casts derive their name is believed to be caused by degenera­
tion of the hyaline cast matrix and any cellular elements or Often referred to as renal failure casts, broad casts like waxy
granules contained in the matrix.22,24 casts represent extreme urine stasis. As a mold of the distal
Waxy casts are more easily visualized than hyaline casts convoluted tubules, the presence of broad casts indicates de­
because of their higher refractive index. As a result of the brittle struction (widening) of the tubular walls. Also, when the flow
consistency of the cast matrix, they often appear fragmented of urine to the larger collecting ducts becomes severely com­
with jagged ends and have notches in their sides (Figs. 6-68 promised, casts form in this area and appear broad.
and 6-69). With supravital stains, waxy casts stain a homoge­ All types of casts may occur in the broad form. However,
nous, dark pink (Fig. 6-70). considering the accompanying urinary stasis, the most com­
monly seen broad casts are granular and waxy (Figs. 6-71 and
6-72). Bile-stained broad, waxy casts are seen as the result of
the tubular necrosis caused by viral hepatitis (Fig. 6-73).

Urinary Crystals
Crystals frequently found in the urine are rarely of clinical sig­
nificance. They may appear as true geometrically formed struc­
tures or as amorphous material. The primary reason for the
identification of urinary crystals is to detect the presence of the
relatively few abnormal types that may represent such disor­
ders as liver disease, inborn errors of metabolism, or renal
damage caused by crystallization of medications compounds
within the tubules. Crystals are usually reported as rare, few,
moderate, or many per hpf. Abnormal crystals may be averaged
and reported per lpf.
Figure 6-68 KOVA-stained waxy casts (x100).

Figure 6-69 KOVA-stained waxy casts (x200). Figure 6-71 KOVA-stained broad waxy cast (x400).
 Chapter 6 | Microscopic Examination of Urine 129

Crystal Formation
Crystals are formed by the precipitation of urine solutes, in­
cluding inorganic salts, organic compounds, and medications
(iatrogenic compounds). Precipitation is subject to changes
in temperature, solute concentration, and pH, which affect
solubility.
Solutes precipitate more readily at low temperatures.
Therefore, the majority of crystal formation takes place in spec­
imens that have remained at room temperature or been refrig­
erated prior to testing. Crystals are extremely abundant in
refrigerated specimens and often present problems because
they obscure clinically significant sediment constituents.
As the concentration of urinary solutes increases, their ability
Figure 6-72 Broad granular cast becoming waxy (x400). to remain in solution decreases, resulting in crystal formation.
The presence of crystals in freshly voided urine is most frequently
associated with concentrated (high specific gravity) specimens.
A valuable aid in the identification of crystals is the pH of
the specimen because this determines the type of chemicals pre­
cipitated. In general, organic and iatrogenic compounds crystal­
lize more easily in an acidic pH, whereas inorganic salts are less
soluble in neutral and alkaline solutions. An exception is calcium
oxalate, which precipitates in both acidic and neutral urine.

General Identification Techniques

The most commonly seen crystals have very characteristic
shapes and colors; however, variations do occur and can present
identification problems, particularly when they resemble ab­
normal crystals. As discussed previously, the first consideration
when identifying crystals is the urine pH. In fact, crystals are
Figure 6-73 Broad bile-stained waxy cast (x400). routinely classified not only as normal and abnormal, but also

Hyaline Sources of error: RBC clumps

Appearance: Colorless, homogenous matrix Reporting: Average number per lpf
Sources of error: Mucus, fibers, hair, increased Complete urinalysis RBCs
lighting correlations: Blood
Reporting: Average number per lpf Protein
Complete urinalysis Protein Clinical significance: Glomerulonephritis
correlations: Blood (exercise) Strenuous exercise
Color (exercise) WBC
Clinical significance: Glomerulonephritis Appearance: Cast matrix containing WBCs
Pyelonephritis Sources of error: WBC clumps
Chronic renal disease Reporting: Average number per lpf
Congestive heart failure Complete urinalysis WBCs
Stress and exercise correlations: Protein
RBC LE
Appearance: Orange-red color, cast matrix Clinical significance: Pyelonephritis
containing RBCs
Acute interstitial nephritis

Continued
130 Part Two | Urinalysis

SUMMARY 6-5 Urine Casts—cont'd

Bacterial Sources of error: Fibers and fecal material

Appearance: Bacilli bound to protein matrix Reporting: Average number per lpf
Sources of error: Granular casts Complete urinalysis Protein
Reporting: Average number per Ipf correlations: Cellular casts
Complete urinalysis WBC casts (pyelonephritis) Granular casts
correlations: WBCs WBCs
LE RBCs
Nitrite Clinical significance: Stasis of urine flow
Protein Chronic renal failure
Bacteria Fatty
Clinical significance: Pyelonephritis Appearance: Fat droplets and oval fat
Epithelial Cell bodies attached to protein
matrix
Appearance: RTE cells attached to protein
matrix Sources of error: Fecal debris

Sources of error: WBC cast Reporting: Average number per lpf

Reporting: Average number per lpf Complete urinalysis Protein

correlations: Free fat droplets
Complete urinalysis Protein
correlations: RTE cells Oval fat bodies

Clinical significance: Renal tubular damage Clinical significance: Nephrotic syndrome

Granular Toxic tubular necrosis

Appearance: Coarse and fine granules in a Diabetes mellitus

cast matrix Crush injuries
Sources of error: Clumps of small crystals Broad
Columnar RTE cells Appearance: Wider than normal cast matrix
Reporting: Average number per lpf Sources of error: Fecal material, fibers
Complete urinalysis Protein Reporting: Average number per lpf
correlations: Cellular casts Complete urinalysis Protein
RBCs correlations: WBCs
WBCs RBCs
Clinical significance: Glomerulonephritis Granular casts
Pyelonephritis Waxy casts
Stress and exercise Clinical significance: Extreme urine stasis
Waxy Renal failure
Appearance: Highly refractile cast with
jagged ends and notches

as to their appearance in acidic or alkaline urine. All abnormal Just as changes in temperature and pH contribute
crystals are found in acidic urine. to crystal formation, reversal of these changes can cause
Additional aids in crystal identification include the use of crystals to dissolve. These solubility characteristics can be
polarized microscopy and solubility characteristics of the crys­ used to aid in identification. Amorphous urates that
tals. The geometric shape of a crystal determines its birefrin­ frequently form in refrigerated specimens and obscure sedi­
gence and, therefore, its ability to polarize light. Although the ments may dissolve if the specimen is warmed. Amorphous
size of a particular crystal may vary (slower crystallization pro­ phosphates require acetic acid to dissolve, and this is
duces larger crystals), the basic structure remains the same. not practical, as formed elements, such as RBCs, will also be
Therefore, polarization characteristics for a particular crystal destroyed. When solubility characteristics are needed
are constant for identification purposes. for identification, the sediment should be aliquoted to
 Chapter 6 | Microscopic Examination of Urine 131

prevent destruction of other elements. In Table 6-6, charac­ Amorphous urates appear microscopically as yellow­
teristics for the most commonly encountered crystals are brown granules (Fig. 6-74). They may occur in clumps resem­
provided. bling granular casts and attached to other sediment structures
(Fig.6-75). Amorphous urates are frequently encountered in
Normal Crystals Seen in Acidic Urine
specimens that have been refrigerated and produce a very char­
The most common crystals seen in acidic urine are urates, con­ acteristic pink sediment. Accumulation of the pigment, uroery-
sisting of amorphous urates, uric acid, acid urates, and sodium thrin, on the surface of the granules is the cause of the pink
urates. Microscopically, most urate crystals appear yellow to color. Amorphous urates are found in acidic urine with a pH
reddish brown and are the only normal crystals found in acidic greater than 5.5, whereas uric acid crystals can appear when
urine that appear colored. the pH is lower.

Table 6-6 Major Characteristics of Normal Urinary Crystals

Crystal pH Color Appearance

Uric acid Acid Yellow-brown (rosettes,

wedges)

Amorphous urates Acid Brick dust or yellow

brown

Calcium oxalate Acid/neutral Colorless (envelopes,

(alkaline) oval, dumbbell)

Amorphous phosphates Alkaline/ White-colorless

neutral

Calcium phosphate Alkaline/ Colorless

neutral

Triple phosphate Alkaline Colorless (“coffin lids”)

Ammonium biurate Alkaline Yellow-brown (“thorny

apples”)

Calcium carbonate Alkaline Colorless (dumbbells)

132 Part Two | Urinalysis

Figure 6-74 Amorphous urates (x400). Figure 6-77 Clump of uric acid crystals (x400). Notice the whetstone,
not hexagonal, shape that differentiates uric acid crystals from cystine
crystals.

cystine crystals (Fig. 6-78 A and B). Increased amounts of uric

acid crystals, particularly in fresh urine, are associated with in­
creased levels of purines and nucleic acids and are seen in pa­
tients with leukemia who are receiving chemotherapy, in
patients with Lesch-Nyhan syndrome (see Chapter 8), and
sometimes in patients with gout.
Acid urates and sodium urates are rarely encountered and,
like amorphous urates, are seen in less acidic urine. They are
frequently seen in conjunction with amorphous urates and

Figure 6-75 Amorphous urates attached to a fiber.

Uric acid crystals are seen in a variety of shapes, including

rhombic, four-sided flat plates (whetstones), wedges, and
rosettes. They usually appear yellow-brown, but may be col­
orless and have a six-sided shape, similar to cystine crystals
(Figs. 6-76 and 6-77). Uric acid crystals are highly birefringent
under polarized light, which aids in distinguishing them from

Figure 6-78 A. Uric acid crystals under polarized light (x100). B. Uric
Figure 6-76 Uric acid crystals (x400). acid crystals under polarized light (x400).
 Chapter 6 | Microscopic Examination of Urine 133

have little clinical significance. Acid urates appear as larger

granules and may have spicules similar to the ammonium
biurate crystals seen in alkaline urine. Sodium urate crystals
are needle-shaped and are seen in synovial fluid during
episodes of gout, but may also appear in the urine.
Calcium oxalate crystals are frequently seen in acidic
urine, but they can be found in neutral urine and even rarely
in alkaline urine. The most common form of calcium oxalate
crystals is the dihydrate that is easily recognized as a colorless,
octahedral envelope or as two pyramids joined at their bases
(Figs. 6-79, 6-80, and 6-81). Less characteristic and less fre­
quently seen is the monohydrate form (Fig. 6-82). Monohy­
drate calcium oxalate crystals are oval or dumbbell shaped.
Both the dihydrate and monohydrate forms are birefringent
under polarized light. This may be helpful to distinguish the
monohydrate form from nonpolarizing RBCs. Calcium oxalate
crystals are sometimes seen in clumps attached to mucous
strands and may resemble casts. Figure 6-81 Attached classic dihydrate calcium oxalate crystals
The finding of clumps of calcium oxalate crystals in fresh (x400).
urine may be related to the formation of renal calculi, because
the majority of renal calculi are composed of calcium oxalate.
They are also associated with foods high in oxalic acid, such

Figure 6-82 Monohydrate calcium oxalate crystals (x400).

as tomatoes and asparagus, and ascorbic acid, because oxalic

acid is an end product of ascorbic acid metabolism. The pri­
mary pathologic significance of calcium oxalate crystals is the
Figure 6-79 Classic dihydrate calcium oxalate crystals (x400).
very noticeable presence of the monohydrate form in cases of
ethylene glycol (antifreeze) poisoning. The monohydrate form
is most frequently seen in children and pets because antifreeze
tastes sweet and uncovered containers left in the garage can be
very tempting! Massive amounts of crystals are frequently pro­
duced in these cases.

Normal Crystals Seen in Alkaline Urine

Phosphates represent the majority of the crystals seen in

alkaline urine and include amorphous phosphate, triple phos­
phate, and calcium phosphate. Other normal crystals associ­
ated with alkaline urine are calcium carbonate and ammonium
biurate. Amorphous phosphates are granular in appearance,
similar to amorphous urates (Figs. 6-83 and 6-84). When
present in large quantities following specimen refrigeration,
they cause a white precipitate that does not dissolve on warm­
Figure 6-80 Classic dihydrate calcium oxalate crystals under phase ing. They can be differentiated from amorphous urates by the
microscopy (x400). color of the sediment and the urine pH.
134 Part Two | Urinalysis

Figure 6-83 Amorphous phosphates (x400). Urine pH 7.0. Figure 6-86 Triple phosphate crystals (arrow) and amorphous phos­
phates (x400).

Figure 6-87 Calcium carbonate crystals (x400).

Figure 6-84 Amorphous phosphates (x400). Triple phosphate crystals are birefringent under polarized light.
They have no clinical significance; however, they are often seen
in highly alkaline urine associated with the presence of urea-
Triple phosphate (ammonium magnesium phosphate) splitting bacteria.
crystals are commonly seen in alkaline urine. In their routine Calcium phosphate crystals are not frequently encoun­
form, they are easily identified by their prism shape that fre­ tered. They may appear as colorless, flat rectangular plates or
quently resembles a “coffin lid” (Figs. 6-85 and 6-86). As they thin prisms often in rosette formations. The rosette forms may
disintegrate, the crystals may develop a feathery appearance. be confused with sulfonamide crystals when the urine pH is
in the neutral range. Calcium phosphate crystals dissolve in
dilute acetic acid and sulfonamides do not. They have no clin­
ical significance, although calcium phosphate is a common
constituent of renal calculi.
Calcium carbonate crystals are small and colorless, with
dumbbell or spherical shapes (Fig. 6-87). They may occur in
clumps that resemble amorphous material, but they can be dis­
tinguished by the formation of gas after the addition of acetic
acid. They are also birefringent, which differentiates them from
bacteria. Calcium carbonate crystals have no clinical significance.
Ammonium biurate crystals exhibit the characteristic
yellow-brown color of the urate crystals seen in acidic urine.
They are frequently described as “thorny apples” because of
their appearance as spicule-covered spheres (Fig. 6-88). Ex­
cept for their occurrence in alkaline urine, ammonium biurate
Figure 6-85 Triple phosphate crystal (x400). crystals resemble other urates in that they dissolve at 60°C and
 Chapter 6 | Microscopic Examination of Urine 135

Figure 6-88 Ammonium biurate crystals (x400). Notice the “thorny

apple” appearance. (Courtesy of Kenneth L. McCoy, MD.)

convert to uric acid crystals when glacial acetic acid is added.

Ammonium biurate crystals are almost always encountered in
Figure 6-90 Ammonium biurate crystals (x400). Note thorns (arrow).
old specimens and may be associated with the presence of the
ammonia produced by urea-splitting bacteria (Figs. 6-89 A
and B and 6-90).
Abnormal Urine Crystals

Abnormal urine crystals are found in acidic urine or rarely

in neutral urine. Most abnormal crystals have very charac­
teristic shapes. However, their identity can be confirmed by
patient information, including disorders and medication
(Table 6-7). Iatrogenic crystals can be caused by a variety
of compounds, particularly when they are administered in
high concentrations. They may be of clinical significance
when they precipitate in the renal tubules. The most com­
monly encountered iatrogenic crystals are discussed in this
section.
Cystine Crystals | c?\ !=»'<-
Cystine crystals are found in the urine of persons who inherit
a metabolic disorder that prevents reabsorption of cystine by
the renal tubules (cystinuria). Persons with cystinuria have a
tendency to form renal calculi, particularly at an early age.
Cystine crystals appear as colorless, hexagonal plates and
may be thick or thin (Figs. 6-91 and 6-92). Disintegrating
forms may be seen in the presence of ammonia. They may be
difficult to differentiate from colorless uric acid crystals. Uric
acid crystals are very birefringent under polarized microscopy,
whereas only thick cystine crystals have polarizing capability
Positive confirmation of cystine crystals is made using the
cyanide-nitroprusside test (see Chapter 8).

Cholesterol Crystals
Cholesterol crystals are rarely seen unless specimens have
been refrigerated, because the lipids remain in droplet form.
However, when observed, they have a most characteristic ap­
pearance, resembling a rectangular plate with a notch in one
or more corners (Fig. 6-93). They are associated with disor­
ders producing lipiduria, such as the nephrotic syndrome, and
Figure 6-89 Ammonium biurate crystals A.Ammonium biurate and are seen in conjunction with fatty casts and oval fat bodies.
triple phosphate crystals (x100). Note thorn (arrow). B. Ammonium Cholesterol crystals are highly birefringent with polarized light
biurate and triple phosphate crystals (x400). (Fig. 6-94).
136 Part Two | Urinalysis

Table 6-7 Major Characteristics of Abnormal Urinary Crystals

Crystal pH Color/Form Disorders Appearance

Cystine Acid Colorless (hexag­ Inherited

onal plates) cystinuria

Cholesterol Acid Colorless Nephrotic

(notched syndrome
plates)

Leucine Acid/neutral Yellow (concen­ Liver disease

tric circles)

Tyrosine Acid/neutral Colorless-yellow Liver disease

(needles)

Bilirubin Acid Yellow Liver disease

Sulfonamides Acid/neutral Varied Infection

treatment

Radiographic dye Acid Colorless Radiographic

(flat plates) procedure

Ampicillin Acid/neutral Colorless Infection

(needles) treatment

Radiographic Dye Crystals

Crystals of radiographic contrast media have a very similar ap­
pearance to cholesterol crystals and also are highly birefringent.
Differentiation is best made by comparison of the other
urinalysis results and the patient history. As mentioned previ­
ously, cholesterol crystals should be accompanied by other
lipid elements and heavy proteinuria. Likewise, the specific
gravity of a specimen containing radiographic contrast media
is markedly elevated when measured by refractometer.

Crystals Associated With Liver Disorders

In the presence of severe liver disorders, three rarely seen crys­
tals may be found in the urine sediment. They are crystals of
Figure 6-91 Cystine crystals (x400). tyrosine, leucine, and bilirubin.
 Chapter 6 | Microscopic Examination of Urine 137

Figure 6-92 Clump of cystine crystals (x400). Notice the hexagonal Figure 6-95 Tyrosine crystals in fine needle clumps (x400).
shape still visible.

Figure 6-96 Tyrosine crystals in rosette forms (x400).

Figure 6-93 Cholesterol crystals. Notice the notched corners
(x400).

Figure 6-97 Leucine crystals (x400). Notice the concentric circles.

Figure 6-94 Cholesterol crystals under polarized light (x400).
are seen less frequently than tyrosine crystals and, when pres­
Tyrosine crystals appear as fine colorless to yellow needles ent, should be accompanied by tyrosine crystals.
that frequently form clumps or rosettes (Figs. 6-95 and 6-96). Bilirubin crystals are present in hepatic disorders produc­
They are usually seen in conjunction with leucine crystals in ing large amounts of bilirubin in the urine. They appear as
specimens with positive chemical test results for bilirubin. clumped needles or granules with the characteristic yellow
Tyrosine crystals may also be encountered in inherited disor­ color of bilirubin (Fig. 6-98). A positive chemical test result
ders of amino acid metabolism (see Chapter 8). for bilirubin would be expected. In disorders that produce
Leucine crystals are yellow-brown spheres that demon­ renal tubular damage, such as viral hepatitis, bilirubin crystals
strate concentric circles and radial striations (Fig. 6-97). They may be found incorporated into the matrix of casts.
138 Part Two | Urinalysis

Figure 6-98 Bilirubin crystals. Notice the classic bright yellow color Figure 6-100 Sulfa crystals, WBCs, and bacteria seen in UTI (x400).
(x400).

Sulfonamide Crystals
Prior to the development of more soluble sulfonamides, the
finding of these crystals in the urine of patients being treated
for UTIs was common. Inadequate patient hydration was and
still is the primary cause of sulfonamide crystallization. The
appearance of sulfonamide crystals in fresh urine can suggest
the possibility of tubular damage if crystals are forming in the
nephron.
A variety of sulfonamide medications are currently on the
market; therefore, one can expect to encounter a variety of
crystal shapes and colors. Shapes most frequently encountered
include needles, rhombics, whetstones, sheaves of wheat, and
rosettes with colors ranging from colorless to yellow-brown
(Figs. 6-99 and 6-100). A check of the patient’s medication
history aids in the identification confirmation.

Ampicillin Crystals
Precipitation of antibiotics is not frequently encountered ex­
cept for the rare observation of ampicillin crystals following
massive doses of this penicillin compound without adequate
hydration. Ampicillin crystals appear as colorless needles that
tend to form bundles following refrigeration (Fig. 6-101 A
and B). Knowledge of the patient’s history can aid in the
identification.

Figure 6-101 Ampicillin crystals. A. Nonrefrigerated ampicillin crys­

tals. (x400). B. Ampicillin crystals after refrigeration (x400).

Urinary Sediment Artifacts

Contaminants of all types can be found in urine, particularly
in specimens collected under improper conditions or in dirty
containers. The most frequently encountered artifacts include
starch, oil droplets, air bubbles, pollen grains, fibers, and fecal
contamination. Because artifacts frequently resemble patho­
logic elements such as RBCs and casts, artifacts can present a
major problem to students. They are often very highly refractile
or occur in a different microscopic plane than the true sedi­
Figure 6-99 Sulfa crystals in rosette form (x400). ment constituents. The reporting of artifacts is not necessary.
 Chapter 6 | Microscopic Examination of Urine 139

Starch granule contamination may occur when corn­

starch is the powder used in powdered gloves. The granules
are highly refractile spheres, usually with a dimpled center
(Fig. 6-102). They resemble fat droplets when polarized, pro­
ducing a Maltese cross formation. Starch granules may also
occasionally be confused with RBCs. Differentiation between
starch and pathologic elements can be made by considering
other urinalysis results, including chemical tests for blood or
protein and the presence of oval fat bodies or fatty casts.
Oil droplets and air bubbles also are highly refractile and
may resemble RBCs to inexperienced laboratory personnel. Oil
droplets may result from contamination by immersion oil or
lotions and creams and maybe seen with fecal contamination
(Fig. 6-103). Air bubbles occur when the specimen is placed
under a cover slip. The presence of these artifacts should be Figure 6-104 Pollen grain. Notice the concentric circles (x400).
considered in the context of the other urinalysis results.
Pollen grains are seasonal contaminants that appear
as spheres with a cell wall and occasional concentric circles
(Fig. 6-104). Like many artifacts, their large size may cause
them to be out of focus with true sediment constituents.
Hair and fibers from clothing and diapers may initially be
mistaken for casts (Figs. 6-105 and 6-106), though they are
usually much longer and more refractile. Examination under
polarized light can frequently differentiate between fibers and
casts (Fig. 6-107). Fibers often polarize, whereas casts, other
than fatty casts, do not polarize.

Figure 6-105 Fiber and squamous epithelial cell (x400).

Figure 6-102 Starch granules. Notice the dimpled center (x400).

Figure 6-106 Fiber under polarized light (x100).

Improperly collected specimens or rarely the presence of

a fistula between the intestinal and urinary tracts may produce
fecal specimen contamination. Fecal artifacts may appear as
plant and meat fibers or as brown amorphous material in a
Figure 6-103 Fecal material and oil artifacts (x400). variety of sizes and shapes (Fig. 6-108).
140 Part Two | Urinalysis

4. Schumann, GB, and Tebbs, RD: Comparison of slides used for

standardized routine microscopic urinalysis. J Med Technol
3(1):54-58, 1986.
5. Addis, T: The number of formed elements in the urinary sedi­
ment of normal individuals. J Clin Invest 2(5):409-415, 1926.
6. Sternheimer, R, and Malbin, R: Clinical recognition of
pyelonephritis with a new stain for urinary sediments. Am J
Med 11:312-313, 1951.
7. Microscope Techniques—Phase Contrast. Web site: http://www
micro.magnet.fsuj.edu/primer/techniques/phase.html
8. Polarizing and Interference Contrast Microscopy. Web site:
http://www rrz.uni-hamburg.de/biologic/b
9. Olympus Microscopy Resource Center: Specialized Microscopy
Techniques: Fluorescence. Web site: http://wwwolympusmicro.
com/ primer/techniques/fluorescence/fluorhome.html. Accessed
December 19, 2006.
Figure 6-107 Diaper fiber resembling a cast. Notice the retractility 10. Simpson, LO: Effects of normal and abnormal urine on red cell
(x400). shape. Nephron 60(3):383-384, 1992.
11. Stapleton, FB: Morphology of urinary red blood cells: A simple
guide in localizing the site of hematuria. Pediatr Clin North Am
34(3):561-569, 1987.
12. Fassett, EG, et al: Urinary red cell morphology during exercise.
Am J Clin Pathol 285(6353):1455-1457, 1982.
13. Kohler, H, Wandel, E, and Brunch, B: Acanthocyturia: A char­
acteristic marker for glomerular bleeding. Int Soc Nephrol
40:115-120, 1991.
14. Tomita, M, et al: A new morphological classification of urinary
erythrocytes for differential diagnosis of hematuria. Clin Nephrol
37(2):84-89, 1992.
15. Haber, MH, Lindner, LE, and Ciofalo, LN: Urinary casts after
stress. Lab Med 10(6):351-355, 1979.
16. Corwin, HL, Bray, RA, and Haber, MH: The detection and
interpretation of urinary eosinophils. Arch Pathol Lab Med
113:1256-1258, 1989.
17. Schumann, GB: Utility of urinary cytology in renal diseases.
Semin Nephrol 5(34) Sept, 1985.
Figure 6-108 Vegetable fiber resembling waxy cast (x400). 18. Graber, M, et al: Bubble cells: Renal tubular cells in the urinary
sediment with characteristics of viability. J Am Soc Nephrol
1(7):999-1004, 1991.
19. Baer, DM: Tips from clinical experts: Reporting of spermatozoa
Log on to
in microscopic urine exams. MLO 12:12, 1997.
www.fadavis.com/strasinger
© for additional content related
to this chapter.
20. Kumar, S, and Muchmore, A: Tamm-Horsfall protein—
Uromodulin, 1950-1990. Kidney Int 37:1395-1399, 1990.
21. Haber, MH: Urinary Sediment: A Textbook Atlas. American
Society of Clinical Pathologists, Chicago, 1981.
22. Lindner, LE, and Haber, MH: Hyaline casts in the urine:
References Mechanism of formation and morphological transformations.
1. Mynahan, C: Evaluation of macroscopic urinalysis as a screen­ Am J Clin Pathol 80(3):347-352, 1983.
ing procedure. Lab Med 15(3):176-179, 1984. 23. Lindner, LE, Jones, RN, and Haber, MH: A specific cast in acute
2. Tetrault, GA: Automated reagent strip urinalysis: Utility in re­ pyelonephritis. Am J Clin Pathol 73(6):809-811, 1980.
ducing work load of urine microscopy and culture. Lab Med 24. Haber, MH, and Lindner, LE: The surface ultrastructure of
25:162-167, 1994. urinary casts. Am J Clin Pathol 68(5):547-552, 1977.
3. CLSI. Urinalysis; Approved Guideline, ed 3. CLSI document 25. Linder, LE, Vacca, D, and Haber, MF: Identification and
GP16-A3, Wayne, PA: Clinical and Laboratory Standards composition of types of granular urinary cast. Am J Pathol
Institute. 2009. 80(3):353-358, 1983.
 Chapter 6 | Microscopic Examination of Urine 141

Study Questions
1. Macroscopic screening of urine specimens is used to: 8. Which of the following are reported as number per lpf?
A. Provide results as soon as possible A. RBCs
B. Predict the type of urinary casts present B. WBCs
C. Increase cost-effectiveness of urinalysis C. Crystals
D. Decrease the need for polarized microscopy D. Casts

2. Variations in the microscopic analysis of urine include all 9. The Sternheimer-Malbin stain is added to urine sediments
of the following except: to do all of the following except:
A. Preparation of the urine sediment A. Increase visibility of sediment constituents
B. Amount of sediment analyzed B. Change the constituents’ refractive index
C. Method of reporting C. Decrease precipitation of crystals
D. Identification of formed elements D. Delineate constituent structures

3. All of the following can cause false-negative microscopic 10. Nuclear detail can be enhanced by:
results except: A. Prussian blue
A. Braking the centrifuge B. Toluidine blue
B. Failing to mix the specimen C. Acetic acid
C. Dilute alkaline urine D. Both B and C
D. Using midstream clean-catch specimens
11. Which of the following lipids is/are stained by Sudan III?
4. The two factors that determine relative centrifugal force are: A. Cholesterol
A. Radius of rotor head and rpm B. Neutral fats
B. Radius of rotor head and time of centrifugation C. Triglycerides
C. Diameter of rotor head and rpm D. Both B and C
D. RPM and time of centrifugation
12. Which of the following lipids is/are capable of polarizing
5. When using the glass slide and cover-slip method, which of light?
the following might be missed if the cover slip is overflowed? A. Cholesterol
A. Casts B. Neutral fats
B. RBCs C. Triglycerides
C. WBCs D. Both A and B
D. Bacteria
13. The purpose of the Hansel stain is to identify:
6. Initial screening of the urine sediment is performed using A. Neutrophils
an objective power of:
B. Renal tubular cells
A. 4x
C. Eosinophils
B. 10x
D. Monocytes
C. 40x
14. Crenated RBCs are seen in urine that is:
D. 100x
A. Hyposthenuric
7. Which of the following should be used to reduce light
B. Hypersthenuric
intensity in bright-field microscopy?
C. Highly acidic
A. Centering screws
D. Highly alkaline
B. Aperture diaphragm
C. Rheostat
D. Condenser aperture diaphragm
142 Part Two | Urinalysis

15. Differentiation among RBCs, yeast, and oil droplets may 23. Forms of transitional epithelial cells include all of the
be accomplished by all of the following except: following except:
A. Observation of budding in yeast cells A. Spherical
B. Increased refractility of oil droplets B. Caudate
C. Lysis of yeast cells by acetic acid C. Convoluted
D. Lysis of RBCs by acetic acid D. Polyhedral

16. A finding of dysmorphic RBCs is indicative of: 24. Increased transitional cells are indicative of:
A. Glomerular bleeding A. Catheterization
B. Renal calculi B. Malignancy
C. Traumatic injury C. Pyelonephritis
D. Coagulation disorders D. Both A and B

17. Leukocytes that stain pale blue with Sternheimer-Malbin 25. A primary characteristic used to identify renal tubular
stain and exhibit brownian movement are: epithelial cells is:
A. Indicative of pyelonephritis A. Elongated structure
B. Basophils B. Centrally located nucleus
C. Mononuclear leukocytes C. Spherical appearance
D. Glitter cells D. Eccentrically located nucleus

18. Mononuclear leukocytes are sometimes mistaken for: 26. Following an episode of hemoglobinuria, RTE cells may
A. Yeast cells contain:
A. Bilirubin
B. Squamous epithelial cells
B. Hemosiderin granules
C. Pollen grains
C. Porphobilinogen
D. Renal tubular cells
D. Myoglobin
19. When pyuria is detected in a urine sediment, the slide
should be carefully checked for the presence of: 27. The predecessor of the oval fat body is the:
A. RBCs A. Histiocyte
B. Bacteria B. Urothelial cell
C. Hyaline casts C. Monocyte
D. Mucus D. Renal tubular cell

20. Transitional epithelial cells are sloughed from the: 28. A structure believed to be an oval fat body produced a
Maltese cross formation under polarized light but does not
A. Collecting duct
stain with Sudan III. The structure:
B. Vagina
A. Contains cholesterol
C. Bladder
B. Is not an oval fat body
D. Proximal convoluted tubule
C. Contains neutral fats
21. The largest cells in the urine sediment are: D. Is contaminated with immersion oil
A. Squamous epithelial cells
29. The finding of yeast cells in the urine is commonly asso­
B. Urothelial epithelial cells ciated with:
C. Cuboidal epithelial cells A. Cystitis
D. Columnar epithelial cells B. Diabetes mellitus
22. A clinically significant squamous epithelial cell is the: C. Pyelonephritis
A. Cuboidal cell D. Liver disorders
B. Clue cell
C. Caudate cell
D. Columnar cell
 Chapter 6 | Microscopic Examination of Urine 143

30. The primary component of urinary mucus is: 38. The presence of fatty casts is associated with:
A. Bence Jones protein A. Nephrotic syndrome
B. Microalbumin B. Crush injuries
C. Uromodulin C. Diabetes mellitus
D. Orthostatic protein D. All of the above
31. The majority of casts are formed in the: 39. Nonpathogenic granular casts contain:
A. Proximal convoluted tubules A. Cellular lysosomes
B. Ascending loop of Henle B. Degenerated cells
C. Distal convoluted tubules C. Protein aggregates
D. Collecting ducts D. Gram-positive cocci
32. Cylindruria refers to the presence of: 40. All of the following are true about waxy casts except they:
A. Cylindrical renal tubular cells A. Represent extreme urine stasis
B. Mucus-resembling casts B. May have a brittle consistency
C. Hyaline and waxy casts C. Require staining to be visualized
D. All types of casts D. Contain degenerated granules
33. A person submitting a urine specimen following a stren­ 41. Observation of broad casts represents:
uous exercise routine can normally have all of the follow­
A. Destruction of tubular walls
ing in the sediment except:
A. Hyaline casts B. Dehydration and high fever

B. Granular casts C. Formation in the collecting ducts

C. RBC casts D. Both A and C

D. WBC casts 42. All of the following contribute to urinary crystals forma­
tion except:
34. Prior to identifying an RBC cast, all of the following
should be observed except: A. Protein concentration

A. Free-floating RBCs B. pH
B. Intact RBCs in the cast C. Solute concentration
C. Presence of a cast matrix D. Temperature
D. A positive reagent strip blood reaction 43. The most valuable initial aid for identifying crystals in a
35. WBC casts are primarily associated with: urine specimen is:

A. Pyelonephritis A. pH

B. Cystitis B. Solubility

C. Glomerulonephritis C. Staining

D. Viral infections D. Polarized microscopy

36. The shape of the RTE cell associated with renal tubular 44. Crystals associated with severe liver disease include all of
epithelial casts is primarily: the following except:
A. Elongated A. Bilirubin
B. Cuboidal B. Leucine
C. Round C. Cystine
D. Columnar D. Tyrosine

37. When observing RTE casts, the cells are primarily: 45. All of the following crystals routinely polarize except:
A. Embedded in a clear matrix A. Uric acid
B. Embedded in a granular matrix B. Cholesterol
C. Attached to the surface of a matrix C. Radiographic dye
D. Stained by components of the urine filtrate D. Cystine
144 Part Two | Urinalysis

46. Casts and fibers can usually be differentiated using: 50. Match the following types of microscopy with their
A. Solubility characteristics descriptions:

B. Patient history -3 Bright-field 1. Indirect light is reflected

off the object
C. Polarized light
"" Phase 2. Objects split light into two
D. Fluorescent light
beams
47. Match the following crystals seen in acidic urine with their "L Polarized 3. Low refractive index
description/identifying characteristics: objects may be overlooked
1. Envelopes I Dark-field 4. Three-dimensional images
3 _ Uric acid 2. Thin needles "". Fluorescent 5. Forms halo of light around
S' Calcium oxalate 3. Yellow-brown, object
monohydrate whetstone Interference 6. Detects electrons
I Calcium oxalate 4. Pink sediment contrast emitted from objects
dihydrate 7. Detects specific wavelengths
5. Ovoid of light emitted from objects

48. Match the following crystals seen in alkaline urine with

their description/identifying characteristics:
Triple phosphate 1. Yellow granules
— Amorphous phosphate 2. Thin prisms
"L Calcium phosphate 3. “Coffin lids”
fa Ammonium biurate 4. Dumbbell shape
5. White precipitate
6. Thorny apple

49. Match the following abnormal crystals with their

description/identifying characteristics:
1. Bundles following
refrigeration
Tyrosine 2. Highly alkaline pH
Cholesterol 3. Bright yellow clumps
4. Hexagonal plates
__ I Ampicillin 5. Flat plates, high
specific gravity
Radiographic dye 6. Concentric circles,
radial striations
3 Bilirubin 7. Notched corners
8. Fine needles seen in
liver disease
 Chapter 6 | Microscopic Examination of Urine 145

Case Studies and Clinical Situations

1. An 85-year-old woman with diabetes and a broken hip Additional testing detects a superinfection with delta
has been confined to bed for the past 3 months. Results hepatitis virus and decreased renal concentrating ability.
of an ancillary blood glucose test are 250 mg/dL, and her Urinalysis results are as follows:
physician orders additional blood tests and a routine COLOR: Amber KETONES: Negative
urinalysis. The urinalysis report is as follows:
CLARITY: Hazy BLOOD: Negative
COLOR: Pale yellow KETONES: Negative
SP GRAVITY: 1.011 BILIRUBIN: Large
CLARITY: Hazy BLOOD: Moderate
pH: 7.0 UROBILINOGEN: 4.0 EU
SP GRAVITY: 1.020 BILIRUBIN: Negative PROTEIN: 2+ NITRITE: Negative
pH: 5.5 UROBILINOGEN: Normal GLUCOSE: Negative LEUKOCYTES: Negative
PROTEIN: Trace NITRITE: Negative Microscopic:
GLUCOSE: 100 mg/dL LEUKOCYTES: 2+ 2 to 4 WBCs/hpf 1 to 2 hyaline casts/lpf
Microscopic: 1 to 3 RBCs/hpf 1 to 2 granular casts/lpf
20 to 25 WBCs/hpf 2 to 4 bile-stained RTE
Many yeast cells and hyphae cells/hpf
a. Why are yeast infections common in patients with 0 to 1 RTE casts/lpf
diabetes mellitus? 0 to 1 bile-stained waxy
b. With a blood glucose level of 250 mg/dL, should casts/lpf
glucose be present in the urine? Why or why not? a. Based on the urinalysis results, in what area of the
c. Is there a discrepancy between the negative nitrite and nephron is damage occurring?
the positive leukocyte esterase results? Explain your b. Is this consistent with the patient’s primary diagnosis?
answer. Explain your answer.
d. What is the major discrepancy between the chemical c. What is causing the RTE cells to be bile stained?
and microscopic results? d. Why is the urobilinogen level elevated?
e. Considering the patient’s history, what is the most e. State a disorder in which the urobilinogen level would
probable cause for the discrepancy? be elevated, but the bilirubin result would be negative.
2. A medical technology student training in a newly reno­ 4. A 30-year-old woman being treated for a UTI brings a
vated STAT laboratory is having difficulty performing a urine specimen to the Employee Health Clinic at 4:00 p.m.
microscopic urinalysis. Reagent strip testing indicates the The nurse on duty tells her that the specimen will be re­
presence of moderate blood and leukocytes, but the stu­ frigerated and tested by the technologist the next morning.
dent is also observing some large unusual objects resem­ The technologist has difficulty interpreting the color of the
bling crystals and possible casts. The student is also reagent strip tests and reports only the following results:
having difficulty keeping all of the constituents in focus
COLOR: Amber CLARITY: Slightly cloudy
at the same time.
Microscopic:
a. Why is the student having difficulty focusing?
3 to 5 RBCs/hpf
b. What is a possible cause of the unusual microscopic
8 to 10 WBCs/hpf
constituents?
Moderate bacteria
c. Should the student be concerned about the unusual
microscopic constituents? Explain your answer. Moderate colorless crystals appearing in bundles
d. What microscopy technique could be used to aid in a. What could have caused the technologist to have
differentiating a cast and an artifact? difficulty interpreting the reagent strip results?
b. Could this specimen produce a yellow foam when
3. A prisoner sentenced to 10 years for selling illegal drugs
shaken?
develops jaundice, lethargy, and hepatomegaly.
A test for hepatitis B surface antigen is positive, and the c. What could the technologist do to aid in the identifi­
patient is placed in the prison infirmary. When his condi­ cation of the crystals?
tion appears to worsen and a low urinary output is ob­ d. What is the probable identification of the colorless
served, the patient is transferred to a local hospital. crystals?
146 Part Two | Urinalysis

5. A 2-year-old left unattended in the garage for 5 minutes SP GRAVITY: 1.030 BILIRUBIN: Negative
is suspected of ingesting antifreeze (ethylene glycol). The pH: 5.5 UROBILINOGEN: Normal
urinalysis has a pH of 6.0 and is negative on the chemical
PROTEIN: 2+ NITRITE: Negative
examination. Two distinct forms of crystals are observed
in the microscopic examination. GLUCOSE: Negative LEUKOCYTE: Negative

a. What type of crystals would you expect to be present? Microscopic:

b. What is the other form of this crystal? 0 to 3 WBCs/hpf

c. Describe the two forms. 0 to 4 hyaline casts/lpf
d. Which form would you expect to be predominant? 0 to 3 granular casts/lpf
Few squamous epithelial cells
6. A female patient comes to the outpatient clinic with
symptoms of UTI. She brings a urine specimen with her. a. Are these results of clinical significance?
Results of the routine analysis performed on this speci­ b. Explain the discrepancy between the chemical and
men are as follows: microscopic blood results.
COLOR: Yellow KETONES: Negative c. What is the probable cause of the granular casts?
CLARITY: Hazy BLOOD: Small 8. As supervisor of the urinalysis section, you are reviewing
SP. GRAVITY: 1.015 BILIRUBIN: Negative results. State why or why not each of the following results
pH: 9.0 UROBILINOGEN: Normal would concern you.
PROTEIN: Negative NITRITE: Negative a. The presence of waxy casts and a negative protein in
urine from a 6-month-old girl
GLUCOSE: Negative LEUKOCYTE: 2+
b. Increased transitional epithelial cells in a specimen
Microscopic:
obtained following cystoscopy
1 to 3 RBCs/hpf Heavy bacteria
c. Tyrosine crystals in a specimen with a negative
8 to 10 WBCs/hpf Moderate squamous bilirubin test result
epithelial cells
d. Cystine crystals in a specimen from a patient diag­
a. What discrepancies are present between the chemical nosed with gout
and microscopic test results?
e. Cholesterol crystals in urine with a specific gravity
b. State a reason for the discrepancies. greater than 1.040
c. Identify a chemical result in the urinalysis that con­ f. Trichomonas vaginalis in a male urine specimen
firms your reason for the discrepancies.
g. Amorphous urates and calcium carbonate crystals in
d. What course of action should the laboratory take to a specimen with a pH of 7.0
obtain accurate results for this patient?

7. A high school student is taken to the emergency room

with a broken leg that occurred during a football game.
The urinalysis results are as follows:
COLOR: Dark yellow KETONES: Negative
CLARITY: Hazy BLOOD: Moderate
 Answers to Study Questions and Case Studies and Clinical Situations 299

22. B 32. B 42. B 6. a. No, the specimen is clear.

23. C 33. A 43. D b. Myoglobinuria.
24. A 34. 1,3,4,2 44. C c. Muscle damage from the accident (rhabdomyolysis).
25. C 35. A 45. B d. Yes. Myoglobin is toxic to the renal tubules.
26. B 36. D 46. C 7. a. Laboratory personnel are not tightly capping the
27. A 37. C 47. C reagent strip containers in a timely manner.
28. D 38. A 48. A b. Personnel performing the CLIA-waived reagent strip
test are not waiting 2 minutes to read the LE reaction.
29. A 39. C 49. C
c. The student is not mixing the specimen.
30. C 40. A
d. The reagent strips have deterioated and the quality
31.1, 2, 1, 2, 1, 2 41. B
control on the strips was not performed prior to
reporting the results.
Case Studies and Clinical Situations
1. a. The blood glucose is elevated and has exceeded the
renal tubular maximum (Tm) for glucose. Chapter 6
b. Diabetes mellitus.
Study Questions
c. It indicates diabetes mellitus related renal disease.
1. A 18. D 35. A
d. Renal tubular reabsorption disorders.
2. D 19. B 36. C
2. a. Yellow foam.
3. C 20. C 37. A
b. Possible biliary-duct obstruction preventing bilirubin
from entering the intestine. 4. C 21. A 38. D

c. Icteric. 5. A 22. B 39. A

d. Protection from light. 6. B 23. C 40. C

3. a. Hemoglobinuria. 7. C 24. D 41. D

b. Increased hemoglobin presented to the liver results 8. D 25. D 42. A

in increased bilirubin entering the intestine for 9. C 26. B 43. A
conversion to urobilinogen. 10. D 27. D 44. C
c. The circulating bilirubin is unconjugated. 11. D 28. A 45. D
d. It would if a multisix reagent strip is used and would 12. A 29. B 46. C
not if a Chemstrip is used. A Watson-Schwartz test is
13. C 30. C 47. 4, 3, 5, 1
more specific for porphobilinogen.
14. B 31. C 48. 3, 5, 2, 6, 4
4. a. Negative chemical reactions for blood and nitrite.
Ascorbic acid interference for both reactions. A ran­ 15. C 32. D 49. 4, 8, 7, 6, 1, 5
dom specimen or further reduction of nitrite could 16. A 33. D 50. 3, 5, 2, 1, 7, 4
cause the negative nitrite. 17. D 34. B
b. Glucose, bilirubin, LE. Ascorbic acid is a strong re­
ducing agent that interfers with the oxidation reaction Case Studies and Clinical Situations
in the glucose test. Ascorbic acid combines with the
diazo reagent in the bilirubin and LE tests, lowering 1. a. Yeast grows best at a low pH with an increased con­
the sensitivity. centration of glucose.

c. The dark yellow color may be caused by beta-carotene b. Yes, this exceeds the renal threshold.
and vitamin A, and some B vitamins also produce c. No, yeast is not capable of reducing nitrate to
yellow urine. nitrite.
d. Non-nitrite-reducing microorganisms; lack of dietary d. Moderate blood with no RBCs.
nitrate; antibiotic administration. e. Myoglobin is the cause of the positive chemical test
5. a. To check for possible exercise-induced abnormal results. result for blood. The patient has been bed-ridden
b. Negative protein and blood, possible changes in color for an extended period of time, causing muscle
and specific gravity. destruction.

c. Renal.
300 Answers to Study Questions and Case Studies and Clinical Situations

2. a. The large objects are in a different plane from that of g. No, calcium carbonate crystals are found in alkaline
the urinary constituents. urine; therefore, clumps of amorphous phosphates
b. Contamination by artifacts. may be present.

c. No, because they are in a different plane.

d. Polarizing microscopy. Chapter 7
3. a. Renal tubules.
b. Yes, viral infections can cause tubular damage. Study Questions
c. RTE cells absorb the bilirubin-containing urinary
1. B 8. D 15. A
filtrate.
2. C 9. A 16. C
d. Liver damage inhibits processing of reabsorbed
urobilinogen. 3. B 10. C 17. A
e. Hemolytic anemia. 4. C 11. C 18. A
4. a. The patient is taking a pigmented medication, such as 5. B 12. C 19. A
phenazopyridine. 6. D 13. B 20. D
b. Yes. 7. C 14. D
c. Ask what medications the patient is taking.
d. Ampicillin. Case Studies and Clinical Situations
5. a. Calcium oxalate. 1. a. Acute glomerulonephritis.
b. Monohydrate and dihydrate calcium oxalate. b. M protein in the cell wall of the group A
c. Oval: monohydrate; envelope: dihydrate. streptococcus.
d. Monohydrate. c. Glomerular bleeding.
6. a. Microscopic results do not match the chemical tests d. No, they are also passing through the damaged
for blood, nitrite, and leukocyte esterase. glomerulus.
b. The specimen has been unpreserved at room temper­ e. Good prognosis with appropriate management of
ature for too long, the cells have disintegrated, and secondary complications.
the bacteria have converted the nitrite to nitrogen. f. Henoch-Schonlein purpura.
c. The pH. 2. a. IgA nephropathy
d. Ask the clinic personnel to instruct the patient to col­ b. Serum IgA level.
lect a midstream clean-catch specimen and have the
c. Chronic glomerulonephritis/end-stage renal
specimen delivered immediately to the laboratory.
disease.
7. a. No, because they are associated with strenuous
d. Impaired renal tubular reabsorption associated with
exercise.
end-stage renal disease.
b. The positive blood reaction is from hemoglobinuria
e. The specific gravity is the same as that of the ultrafil­
or myoglobinuria resulting from participating in a
trate, indicating a lack of tubular concentration.
contact sport. The protein is orthostatic.
f. The presence of extreme urinary stasis.
c. Increased excretion of RTE cell lysosomes in the
presence of dehydration. 3. a. Nephrotic syndrome.
8. a. Yes, the waxy casts are probably an artifact such as b. Nephrotic syndrome may be caused by sudden,
a diaper fiber. Waxy casts are not associated with severe hypotension.
negative urine protein. c. Changes in the electrical charges of the shield of
b. No, this is normal following an invasive procedure. negativity produce increased membrane permeability.

c. Yes, tyrosine crystals are seen in severe liver disease; d. Decreased plasma albumin lowers the capillary on­
therefore, the bilirubin should be positive. The cotic pressure, causing fluid to enter the interstitial
crystals may be an artifact or from a medication. tissue.

d. Yes, uric acid crystals may be mistaken for cystine e. Reabsorption of filtered lipids by the RTE cells.
crystals. 4. a. Minimal change disease.
e. Yes, radiographic dye crystals associated with a high b. Nephrotic syndrome, focal segmental
specific gravity resemble cholesterol crystals. glomerulosclerosis.
f. No, Trichomonas is carried asymptomatically by men. c. Good prognosis with complete remission.
 Introduction
• Microscopic examination of the urinary sediment
• Identification of insoluble substances (formed elements)
- Red blood cells (RBCs)
- White blood cells (WBCs)
- Epithelial cells
- Casts
- Bacteria
- Yeast
- Parasites
- Mucus
- Spermatozoa
- Crystals
- Artifacts
• Least standardized, most time consuming

Copyright © 2014. F.A. Davis Company Fea. davis company]

 Macroscopic Screening

• Microscopic is performed based on physical and

chemical results
• Color, clarity, blood, protein, nitrite, leukocyte
esterase, and possibly glucose
• Special populations: pregnant women; pediatric,
geriatric, diabetic, immunocompromised, and
renal patients

© 2014. F.A. Davis Company Fea. davis COMPANY

Clinical and Laboratory Standards
Institute (CLSI)

• Requested by the physician

• Laboratory-specified population
• Any abnormal physical or chemical result

\ I .A. DAVIS MM COMPANY

© 2014. F.A. Davis Company
 Specimen Preparation

Examine when fresh or preserved

— RBCs, WBCs, casts disintegrate in dilute, alkaline
Refrigeration precipitates crystals
— Can obscure other elements
• Less contamination (epithelial cells) from a
midstream clean-catch specimen
• Thoroughly mix specimen before decanting to
the centrifuge tube
I .A. DAVIS MM COMPANY
© 2014. F.A. Davis Company
 Specimen Volume

• Centrifuge 10 to 15 mL urine (reagent strips fit

into 12 mL)
• Quantities <12 mL should be documented
• Too little volume = fewer formed elements
• Some laboratories correct for volume

F.A. DAVIS COMPANY

© 2014. F.A. Davis Company
 »__ Centrifugation
5000 rvm per minute (5 minutes) \

Standardize speed and time of centrifugation

5 min at relative centrifugal force (RCF) of 400 is
ideal
• RCF corrects for variations in the diameter of
centrifuge heads; revolutions per minute does not
• RCF = 1.118 x 10-5 x radius in centimeters x RPM2
• Do not brake the centrifuge
• Cap all specimens

Copyright © 2014. F.A. Davis Company Fea. davis COMPANY

 Sediment Standardization
• Preparation of sediment
• Volume of sediment examined
— 0.5 to 1.0 mL
• Methods of visualization
• Reporting of results
• Commercial systems: KOVA
- Calibrated centrifuge tubes, special slides to control
volume, decanting pipettes, grids for better
quantitation
© 2014. F.A. Davis Company Fea. davis COMPANY
 Postcentrifuge Sediment

0.5 to 1.0 mL after decantation you can use a pipette

Concentration factor: volume of urine
centrifuged/sediment volume
— Probability of detecting low quantities of formed
elements
• Aspirate rather than pour off urine (pipettes
available for this)
• Mix sediment gently, not vigorously
*

\ I .A. DAVIS MM COMPANY

© 2014. F.A. Davis Company
 Volume of Sediment Examined

• Be consistent
• Commercial systems control this
• Glass slide method
- 20 pL
— 22 x 22 glass cover slip
— Do not overflow cover slip
• Heavier elements (casts) flow outside

\ I .A. DAVIS MM COMPANY

© 2014. F.A. Davis Company
 Examination of Sediment
• Be consistent
Minimum 10 low (10x) and 10 high (40x) fields
Low power: casts, general composition
- Scan edges for casts with glass slide method
High power: identification of type FOLLOW "AB PROOCOL

Initial focusing: low power, reduced light

— Focus on epithelial cell, not artifacts that are in a
different plane
• Use fine adjustment continuously for best view
© 2014. F.A. Davis Company [ea. davis COMPANY
 Reporting the Microscopic
Examination
• Consistent within laboratory Follow lab policy

• Casts: average per Ipf

• RBCs, WBCs: average per hpf
• Epithelial cells, crystals, etc., in semiquantitative terms
— Few, moderate, many
— 1+, 2+, 3+, 4+
— Follwed by /lpf or /hpf

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Copyright © 2014. F.A. Davis Company
 Correlating Results
Microscopic Physical Chemical Exceptions
Elements according to the cloudiness

RBCs Turbidity + Blood Number

Red color + Protein Hemolysis
WBCs Turbidity + Protein Number
+ Nitrite Lysis
+ LE
Epithelial cells Turbidity Number
Casts + Protein Number
Bacteria Turbidity pH Number and type
+ Nitrite
+ Leukocytes
Crystals Turbidity pH Number and type
Color + Bilirubin

Copyright © 2014. F.A. Davis Company Fea. davis COMPANY

 Sediment Examination
Techniques
• Sediment appearance
— Cells and casts in various stages of development and
degeneration
— Distortion of cells and crystals by the chemical content of the
specimen
— The presence of inclusions in cells and casts
— Contamination by artifacts
you should differentiate between artifacts and casts

Copyright © 2014. F.A. Davis Company Fea. davis COMPANY

 Cytodiagnostic Urine Testing
• Cytodiagnostic urine testing is frequently performed to
detect and monitor renal disease/malignancies
• Preparation of permanent slides using
cytocentrifugation
• Papanicolaou stain
— Transplant rejection
— Viral, fungal, and parasitic infections
— Cellular inclusions
— Pathologic casts
— Inflammatory conditions

© 2014. F.A. Davis Company Fea. davis COMPANY

 Urine Sediment Constituents
0 -1 if very small amount which can also be considered
normal

• Small amounts of constituents can be normal

or pathogenic based on the clinical picture
• Many urines have just a rare epithelial cell
• Some constituents are easily distorted
- Concentrations, pH, and presence of metabolites
• Normals are not clearly defined

F.A. DAVIS COMPANY

© 2014. F.A. Davis Company
 Identification difficulties
— Yeast: look for buds
— Oil droplets: refractility
— Air bubbles: refractility
and possibly in a different
plane
— Starch: refractile,
polarizes
— Reagent strip correlation

Copyright © 2014. F.A. Davis Company [ea. davis company]

 RBCs (cont’d)
when concentrated urine, then RBCs will be lysed

• Smooth, nonnucleated,
biconcave disks ~7 pm
• Crenated in
hypersthenuric urine
• Ghost cells in
hyposthenuric urine
• Identify using high
power

© 2014. F.A. Davis Company

 RBCs (cont’d)

Air Bubble Oil Droplets

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 RBCs (cont’d)

• Dysmorphic RBCs
— Glomerular bleeding
- Strenuous exercise
- Acanthocytic, blebs
— Fragmented, hypochromic
— Aid in diagnosis

I .A. DAVIS MM COMPANY

© 2014. F.A. Davis Company
 Clinical Significance
• Normal value: 0-3 to 5/hpf
• Damage to glomerular membrane or vascular
injury to the genitourinary tract
• Number of cells = extent of damage
• Macroscopic versus microscopic hematuria
- Cloudy, red urine, advanced disease, trauma, acute
infection, coagulation disorders
— Clear urine, early glomerular disease, malignancy,
strenuous exercise, renal calculi confirmation
© 2014. F.A. Davis Company [ea. davis COMPANY
 WBCs

• 12 pm
Neutrophil is
predominant
Identify under high power
Glitter cells
- Hypotonic urine
- Brownian movement
- Swell; granules sparkle
- Pale blue if stained
- Nonpathologic

Copyright © 2014. F.A. Davis Company Fea. davis COMPANY

 WBCs (cont’d)

• Glitter cell

Copyright © 2014. F.A. Davis Company Fea. davis company]

 Clinical Significance
• Normal = <5 per hpf, more in females
• May enter through glomerulus or trauma but also by
amoeboid migration
• Increased WBCs = pyuria
• Infections: cystitis, pyelonephritis, prostatitis,
urethritis
• Glomerulonephritis, lupus erythematosus,
interstitial nephritis, tumors
• Report presence of bacteria
*
\ I .A. DAVIS MM COMPANY
© 2014. F.A. Davis Company
 Epithelial Cells
Significance depending on the type Three types
1. Squamous
2. Transitional (urothelial)
3. RTE
Classification
- Squamous: vagina, male and
female urethra
- First structures observed
- Transitional: bladder, renal
pelvis, calyces, ureters,
upper male urethra
- RTE: renal tubules
Fea. davis company]
Copyright © 2014. F.A. Davis Company
 Squamous Epithelial Cells
Sometimes colored depending on pigments

• Largest cell in urine

• Good for focusing
microscope
• Rare, few, moderate,
many
• lpf or hpf per laboratory
• Normal sloughing
• Contamination if not
midstream clean-catch
*

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Copyright © 2014. F.A. Davis Company
 Squamous Epithelial Cells (cont’d)

Copyright © 2014. F.A. Davis Company [f.A. DAVIS COMPANY]

 Clue Cells
sometimes it is having bacteria that is infecting the vagina and wet mount is ordered

• Squamous cell with pathologic significance

• Gardnerella vaginalis: vaginal infection
• Coccobacillus sp. covers most of the cell and
extends over the edges
• Seen in urine but more common in vaginal wet
preparation

F.A. DAVIS COMPANY

© 2014. F.A. Davis Company
 Transitional Epithelial
(Urothelial) Cells
• Three forms
1. Spherical: absorb water in bladder and become large and
round
2. Caudate: appear to have a tail
3. Polyhedral: multiple sides
• Differentiate from RTE
— Centrally located nucleus
• Syncytia = clumps
— Catheterization
— Malignancy

© 2014. F.A. Davis Company Fea. davis COMPANY

 Transitional Epithelial
(Urothelial) Cells (cont'd)
spherical
polyhedral
caudate

F.A. DAVIS COMPANY

© 2014. F.A. Davis Company
 Renal Tubular Epithelial Cells
just know how to differentiate not from where

• Size and shape vary with renal tubular area

• Columnar = proximal convoluted tubule (PCT)
• Round, oval = distal convoluted tubule (DCT)
• Cuboidal = collecting duct
• Three or more cuboidal cells = renal fragment

© 2014. F.A. Davis Company Fea. davis COMPANY

 PCT Cells

• Larger than other RTEs

• Columnar, convoluted,
rectangular
• May resemble casts
• Coarsely granular
cytoplasm
• Notice presence of
nucleus
having nucleus that makes them different than cast

© 2014. F.A. Davis Company Fea. davis COMPANY

 Collecting Duct RTEs

• Cuboidal, never round

— At least one straight
edge
— Eccentric nucleus
• Three or more cells in
clump is renal fragment;
often large sheets
• PCT and DCT not seen in
clumps

© 2014. F.A. Davis Company Fea. davis COMPANY

 Clinical Significance
• RTE cells are the most clinically significant urine
epithelial cells; indicate tubular necrosis;
fragments indicate severe destruction
- Heavy metals, drug toxicity, hemoglobin, myoglobin,
viral infections, pyelonephritis, transplant rejection,
salicylate poisoning cells pass in urine
• Single cuboidal cells = salicylate poisoning
• Absorb: bilirubin, hemoglobin, lipids
• Hemosiderin stains with Prussian blue
© 2014. F.A. Davis Company [ea. davis COMPANY
 RTE cells

F.A. DAVIS COMPANY

Copyright © 2014. F.A. Davis Company 4
>
 Oval Fat Bodies

• RTE cells that have

absorbed lipid in the
filtrate
• Also free-floating
refractile droplets
• Maltese cross formation
with polarized light
• If negative check with
Sudan III or oil red O stain

Copyright © 2014. F.A. Davis Company Fea. davis COMPANY

 Bacteria
Urine is usually sterile,
contaminated on the way out;
contaminants multiply fast
WBCs should accompany
Nitrite enzyme
bacteria in UTI
Report few, moderate, many
per hpf
Rods and cocci may be seen;
rods most common
Nitrite helps to confirm rods,
not cocci

Copyright © 2014. F.A. Davis Company Fea. davis COMPANY

 Yeast

• Single, refractile, budding structures

• Mycelial forms may be present
• Report: few, moderate, many
• Diabetic urine: ^ glucose and acid ideal for yeast
growth
• Immunocompromised, vaginal moniliasis
• Nitrite negative, WBCs present
• Confuse with RBCs
*

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© 2014. F.A. Davis Company
 1
Yeast (cont’d)

F.A. DAVIS company]

Copyright © 2014. F.A. Davis Company
 Parasites

Most common: Trichomonas vaginalis

- Pear-shaped flagellate in wet mount of the vagina
— Swims across field rapidly
Report few, moderate, many
If not moving, may resemble WBC, transitional,
or RTE cells
Also Schistosoma haematobium and Enterobius
vermicularis
F.A. DAVIS COMPANY
© 2014. F.A. Davis Company
 Parasites (cont’d)

Copyright © 2014. F.A. Davis Company [ea. davis company]

 Spermatozoa
Oval, tapered heads and long tail
when sperm is expelled in bladder rather than the urethra
Urine is toxic to sperm, so they
are immobile
Rarely significant, infertility:
sperm expelled into bladder
instead of urethra
May cause positive protein
Reporting varies with
laboratories
Lack of clinical significance, legal
consequences

Copyright © 2014. F.A. Davis Company Fea. davis company]

 Mucus

• Protein from RTE,

glands, squamous cells
Threadlike, low confused with hyaline cast
refractive index
• Confuse with casts
— Irregular, composed of
uromodulin protein
• Female specimens, no
clinical significance

Copyright © 2014. F.A. Davis Company Fea. davis COMPANY

 very specific to the kidneys
Casts

• Elements unique to the kidney

• Formed in DCT and collecting duct zT
• Parallel sides, rounded ends, inclusions /j
• Detect under low power, ID high power
• Scan edges of glass cover slip
• Low light is essential
• Report number per lpf
• Many pathologic and nonpathologic causes
*
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© 2014. F.A. Davis Company
 Composition and Formation

Uromodulin protein secreted by RTE of DCT and

collecting duct
• Consistent excretion normally
— f stress and exercise
• Formation of protein fibrils into matrix
- Urine stasis, acid pH, Na, and Ca
• Uromodulin protein not detected by reagent strips
• f protein is from renal disease

© 2014. F.A. Davis Company Fea. davis COMPANY

 Composition and Formation (cont’d)

• Formation
- Aggregated uromodulin fibrils attached to RTEs
— Interweaving to loose network, traps elements
— More interweaving to form solid matrix
— Attachment of elements to matrix
— Detachment of fibrils from RTEs
— Excretion of cast
• Cylindroids
— Tapered ends, one or both
— Same significance as cast
F.A. DAVIS COMPANY
Copyright © 2014. F.A. Davis Company
 Hyaline Casts

Low refractive index

Colorless when unstained
Uromodulin protein
Use low light or phase
Normal parallel sides or
convoluted, wrinkled,
cylindroid, occasional
adhering cell or granule

Copyright © 2014. F.A. Davis Company Fea. davis company]

 Clinical Significance
Most frequently seen
0 to 2 is normal
Nonpathologic: stress,
exercise, fever, heat
exposure, dehydration
Pathologic:
glomerulonephritis,
pyelonephritis, chronic
renal disease, congestive
ast can never be seen in cystitis or urethritis bec the tubules are in the
idneys not urethra or bladder heart failure
Copyright © 2014. F.A. Davis Company [ea. davis COMPANY
 Clinical Significance (cont’d)

F.A. DAVIS
© . F.A. Davis Company
>
 RBC Casts
• Orange-red color
• Embedded and
adhering cells
• May be fragmented
• Confirm seeing free
RBCs and positive
reagent strip for blood
• Look for cast matrix to
avoid mistaking a RBC
clump for a cast
Copyright © 2014. F.A. Davis Company Fea. davis COMPANY
 Clinical Significance

• Bleeding within the nephron, casts are more

specific than free RBCs in urine
• Glomerular damage or nephron capillary damage
• Glomerular damage: dysmorphic RBCs and
elevated protein
• May be seen following strenuous exercise
always expect the presence of chronic disease in the kidney when there is high level of albumin "High proteins in
strips"

© 2014. F.A. Davis Company [ea. davis COMPANY

 Clinical Significance (cont’d)

• Cells begin to disintegrate

with more stasis of urine
flow
• Hemoglobin and myoglobin
damage tubules
• Hemoglobin degraded to
methemoglobin = dirty
brown casts
• Look for RTE cells to confirm
tubular necrosis

Copyright © 2014. F.A. Davis Company Fea. davis COMPANY

 WBC Casts
• Mostly neutrophils and
lobed nucleus and
granules are seen
• Staining helps
differentiate from RTE
cells
• May be tightly packed;
look for cast matrix to
distinguish from WBC
clump NO CAST = NO MATRIX

Copyright © 2014. F.A. Davis Company Fea. davis COMPANY

 WBC Casts (cont’d)
THERE SHOULD BE FREE WBCs OUT TO CONFIRM CAST

• WBC casts are seen with

infection and inflammation
of the tubules
• Pyelonephritis: WBC casts,
bacteria
• Acute interstitial nephtitis:
WBC casts, no bacteria
• May accompany RBC casts

Copyright © 2014. F.A. Davis Company Fea. davis company]

 Bacterial Casts

• May be pure bacteria or mixed with WBCs

• Resemble granular casts
• Look for free WBCs and bacteria
• Confirm with Gram stain
• Seen in pyelonephritis
• Mixed cellular casts
— Glomerular nephritis: RBCs and WBCs
• Look for predominant type of cell
© 2014. F.A. Davis Company Fea. davis COMPANY
 Epithelial (RTE) Casts
• Formed in DCT = small, transitional and RTE can be confused with WBCs
round cells but WBCs are having different nucleus

• Fibrils forming cast pull

cells from damaged
tubules
• Majority of cells are on
the cast matrix
• Differentiate from WBCs:
stain to show single
nucleus
Copyright © 2014. F.A. Davis Company Fea. davis company]
 Clinical Significance

• Tubular damage, heavy

metals, viral infections,
drug toxicity, graft
rejection, pyelonephritis
• Cells may appear bilirubin
stained
• Look for matrix to
distinguish fragments

"f.a. davis COMPANY

© 2014. F.A. Davis Company
 If albumin is there, then check for cast because there is an issue with the kidneys

Fatty Casts
• Seen with oval fat bodies
(OFBs) and fat droplets
• Highly refractile, OFBs
may attach to matrix
• Polarized microscopy and
lipid stains
• Nephrotic syndrome,
diabetes, crush trauma,
tubular necrosis

Copyright © 2014. F.A. Davis Company Fea. davis company]

 Mixed Cellular Casts

• RBC and WBC casts in glomerulonephritis

• WBC and RTE cell casts, or WBC and bacterial
casts in pyelonephritis
• Identification difficult
- Staining or phase microscopy aids in the
identification

*
\ I .A. DAVIS MM COMPANY
© 2014. F.A. Davis Company
 Granular Casts

• Coarse and finely granular

• Granule origin
- RTE lysosomes, excreted
in normal metabolism,
more after exercise and
activity
- Disintegration of cellular
casts and free cells

Copyright © 2014. F.A. Davis Company Fea. davis company]

 Granular Casts (cont’d)

broad cast are dangerous "any cast can be"

• Detect with low power, ID waxy is related to renal failure also but not as dangerous as broad

with high power

• Granules disintegrate to
form waxy casts
• Differentiate granular
casts from clumps of
debris and crystals; look
for matrix

© 2014. F.A. Davis Company Fea. davis COMPANY

 Waxy Casts

• Brittle, highly refractile

• Often fragmented with
jagged ends and notches
• Well visualized with stain
• Degenerated hyaline and
granular casts
• Extreme urine stasis
• Renal failure

© 2014. F.A. Davis Company Fea. davis company]

 relate the microscopic to chemical and medical

Broad Casts
diabetes and ketones and yeast with diabetes

• Renal failure casts

• Destruction and widening of
the DCTs
• Formation in the upper
collecting duct
• All types of casts may be
broad
• Most common are granular
and waxy
• Bilirubin stained from viral
hepatitis
Copyright © 2014. F.A. Davis Company Fea. davis company]
 Urinary Crystals
many are normal especially if stayed for long time but if it is fresh urine then report

• Most are not clinically significant but are reported

• True geometrically formed structures or as amorphous
material
• Must differentiate from the few abnormal crystals
indicating liver disease, inborn errors of metabolism,
and damage to tubules
• Iatrogenic: caused by medications or treatments
• Report: rare few, moderate, many

© 2014. F.A. Davis Company Fea. davis COMPANY

 Crystal Formation

• Precipitation of urine solutes: salts, organic

compounds, and medications
• Formation based on temperature, solute
concentration,7 and pH
~
we usually see amorphous (Urate/phosphate)
depending on the pH (Urate in acidic)

• Many crystals in refrigerated specimens

• High specific gravity needed in fresh specimens

*
\ I .A. DAVIS MM COMPANY
© 2014. F.A. Davis Company
General Identification Techniques

• Most have characteristic shapes and colors

• Most valuable ID is urine pH
• Classification: normal acid, normal alkaline
• All abnormal crystals are found in acid urine
• Polarized microscopy characteristics are valuable
in ID
*
\ I .A. DAVIS MM COMPANY
© 2014. F.A. Davis Company
 Solubility Characteristics

• Temperature and pH contribute to formation and

solubility
• Amorphous urates form in refrigerated acid
urine; will dissolve with heat
• Amorphous phosphates form in refrigerated
alkaline urine; will dissolve in acetic acid; so will
RBCs

© 2014. F.A. Davis Company Fea. davis COMPANY

 Normal Crystals in Acid Urinenot significant but can obstructs the vision for stuff
underneath

• Amorphous urates
— Yellow-brown granules
microscopically
— Urine sediment has pink
color due to the pigment
uroerythrin attaching on
surface of granules
— Often in clumps; may
resemble/casts—'> <
— pH usually greater than
5.5

Copyright © 2014. F.A. Davis Company Fea. davis company]

 Uric Acid Crystals
Yellow to gold

Rhombic, whetstones, no need to know the shape, just know

wedges, rosettes that they are al1 the same

Yellow-brown color
May resemble cystine
crystals but always
polarize
f purines, nucleic acids
Chemotherapy for
leukemia, gout
© 2014. F.A. Davis Company Fea. davis COMPANY
 Calcium Oxalate Crystals
Most common

• Acid and neutral pH

• Dihydrate is envelope or
two pyramid-shaped
— Most common
• Monohydrate is oval or
dumbbell shaped
— Antifreeze poisoning
• Calcium oxalate is a major
component of renal calculi

© 2014. F.A. Davis Company Fea. davis COMPANY

 Amorphous Phosphates
calcium phosphate

• May appear similar to

amorphous urates
• Differentiate
- Alkaline pH and heavy
white precipitate after
refrigeration

Copyright © 2014. F.A. Davis Company Fea. davis company]

 Normal Crystals in Alkaline Urine

• Triple phosphate
• Colorless, prism, or coffin­
lid shaped
• Highly alkaline urine and
urinary tract infections
(UTIs)
• Polarize
• No clinical significance

Copyright © 2014. F.A. Davis Company Fea. davis COMPANY

 Calcium Phosphate and Carbonate
not very significant

• Phosphate
- Flat rectangles and thin
prisms in rosettes
- No clinical significance
• Carbonate
- Small, dumbbell, and
spherical shapes
- Gas produced with
addition of acetic acid
- No clinical significance
Copyright © 2014. F.A. Davis Company [ea. davis company]
 Ammonium Biurate Crystals

• Yellow-brown, spicule- like fire

covered spheres; “thorny

apples”
• Only urates in alkaline
urine
• Old specimens and with
urea-splitting bacteria

*
r|.A. DAVIS aMlCOMPANY
© 2014. F.A. Davis Company
 Abnormal Crystals
we don't have clinical history so we cant identify them

• Cystine crystals
- Hexagonal, thin and thick
plates
- Similar to uric acid
- UA polarizes but only thick
cystine crystals polarize
- Seen in cystinuria: inability
to reabsorb cystine
- Confirm: cyanide
nitroprusside

Copyright © 2014. F.A. Davis Company Fea. davis company]

 Cholesterol Crystals
not easily seen unless refrigerated

• Refrigerated specimens
• Rectangular plates with
characteristic notched
corners
• Highly birefringent
• Nephrotic syndrome
accompanying fatty casts
and OFBs

Copyright © 2014. F.A. Davis Company Fea. davis company]

 Radiographic Dye Crystals

• Radiographic dye
- Similar to cholesterol crystals, polarize
- Patient history
- Very high SG with refractometer

11 .A. DAVIS MM COMPANY

© 2014. F.A. Davis Company
 Liver Disease Crystals
• Tyrosine crystals
— Fine yellow needles in
clumps or rosettes
— Seen with leucine
crystals
— Inherited amino acid
disorders
• Leucine crystals
— Yellow-brown spheres
with concentric circles
and radial striations

Copyright © 2014. F.A. Davis Company Fea. davis COMPANY

 Liver Disease Crystals (cont'd)

Bilirubin crystals
- Clumped needles or
granules
- Characteristic yellow
color
- Viral hepatitis with
tubular damage
- Positive reagent strip for
bilirubin

Copyright © 2014. F.A. Davis Company Fea. davis COMPANY

 Sulfonamide Crystals
caused by drugs

Look like scratches to be careful

• Possibility of tubular
damage if crystals are
forming in the nephron
• Shapes most frequently
encountered include
needles, rhombics,
whetstones, sheaves of
wheat, and rosettes with
colors ranging from
colorless to yellow-brown

[EA. DAVIS COMPANY

Copyright © 2014. F.A. Davis Company
I

Ampicillin Crystals
Precipitation of antibiotics

looks like scratches

• Ampicillin crystals
appear as colorless
needles that tend to
form bundles following
refrigeration

Copyright © 2014. F.A. Davis Company

 Urinary Sediment Artifacts

• Material fibers, meat

and vegetable fibers,
and hair
• Starch, oil droplets, air
bubbles, pollen grains,
vegetable fiber, hair,
diaper fiber

COMPANY
© 2014. F.A. Davis Company
 Urinary Sediment Artifacts (cont'd)

[EA. DAVIS COMPANY]

Copyright © 2014. F.A. Davis Company 4
Microscopic Examination of Urine

Multiple Choices

1. The number of fields that should be examined when quantitating urinary sediment constituents is:
A.) 2
B) 5
*C) 10
D) 20

2. The purpose of scanning the perimeter of urine sediment placed under a conventional glass slide is to:
A) Identify types of casts
B) Detect renal tubular epithelial cells
C) Evaluate the overall sediment composition
*D) Detect the presence of casts

3. All of the following are reported as the quantity per high-power field except:
*A) Casts
B) Red blood cells (RBCs)
C) White blood cells (WBCs)
D) Bacteria

4. A medical laboratory science student consistently obtains lower RBC counts than the instructor. A
possible reason for this might be:
*A) Failure to completely resuspend the sedimented specimen
B) Reading the same cells twice
C) Counting all crenated cells twice
D) Using too much stain

5. To detect the presence of casts, the sediment is examined using:

A) Increased light under high power
B) Increased light under low power
C) Reduced light under high power
*D) Reduced light under low power

6. The presence of crenated RBCs in the urine sediment is associated with:

A) Rrauma
*B) Hypersthenuria
C) Hyposthenuria
D) Urinary tract infection

7. Dilute alkaline urine should be examined carefully for the presence of:
A) Yeast
B) Renal tubular epithelial cells
*C) Ghost RBCs
D) Fatty casts
8. Ghost RBCs most frequently occur with a urine specimen that exhibits the following:
A) High pH, high specific gravity
*B) High pH, low specific gravity
C) Low pH, high specific gravity
D) Low pH, low specific gravity

9. An increase in urinary WBCs is called:

A) Pyelonephritis
B ) Cystitis
C) Urethritis
*D) Pyuria

10. Urine sediments containing increased WBCs should be observed closely for the presence of:
A) Hyaline casts
B) Granular casts
*C) Bacteria
D) Urothelial cells

11. Oval fat bodies are:

A) Squamous epithelial cells that contain lipids
*B) Renal tubular epithelial cells that contain lipids
C) WBCs that have phagocytized lipids
D) People who fail to work out regularly

12. The type of cells that line the bladder and ureters are called:
A) Squamous
B) Renal tubular
*C) Transitional
D) Basal

13. Initial microscopic focusing on the urinary sediment is frequently performed by referencing:
A) Mucus
*B ) Squamous epithelial cells
C) RBCs
D) Hyaline casts

14. Clue cells are derived from:

A) Renal tubular epithelial cells
B) Trichomonas vaginalis
C) Histiocytes
*D) Squamous epithelial cells

15. The organisms attached to a clue cell are:

*A) Gardnerella vaginalis
B) Trichomonas vaginalis
C) Escherichia coli
D) Candida albicans
16. Which of the following cells found in increased numbers in the urine sediment is only indicative of
nephron damage?
A) Erythrocytes
B) WBCs
C) Squamous epithelial cells
*D) Renal tubular cells

17. Collection of a midstream clean-catch specimen will alleviate contamination by:

A) Renal tubular epithelial cells
B) RBCs
C) Transitional epithelial cells
*D) Squamous epithelial cells

18. Spherical transitional epithelial cells can be differentiated from renal tubular epithelial cells by
observing the:
A) Centrally located nucleus in renal tubular cells
B) Granular cytoplasm in renal tubular cells
*C) Centrally located nucleus in transitional cells
D) Granular cytoplasm in transitional cells

19. The primary factor that favors the formation of urinary casts is:
*A) Urinary stasis
B) High pH
C) Positive blood
D) Low specific gravity

20. The major constituent of urinary casts is:

A) Lipoprotein
B) Bence Jones protein
*C) Uromodulin protein
D) Amino acids

21. Waxy casts are most easily differentiated from hyaline casts by their:
A) Color
B) Size
C) Granules
*D) Refractivity

22. Urinary casts are formed in the:

*A) Distal and collecting tubules
B) Distal tubules and loops of Henle
C) Proximal and distal tubules
D) Proximal tubules and loops of Henle

23. Which of the following elements would most likely be found in an acidic concentrated urine that
contains protein?
A) Ghost RBCs
*B) Casts
C) Bacteria
D) Triple phosphate crystals
24. Sediment constituents that are used to differentiate between upper and lower urinary tract infections
are:
A) WBCs
B) WBC clumps
C) RBCs and WBCs
*D) WBC casts

25. The type of cast most closely associated with tubular damage is the:
A) WBC cast
*B) Epithelial cell cast
C) RBC cast
D) Fatty cast

26. Broad casts may form as a result of:

*A) Extreme urinary stasis
B) Strenuous exercise
C) Increase in loss of amino acids
D) Dehydration

27. The finding of increased hyaline and granular casts in the urine of an otherwise healthy person may be
the result of:
A) Fecal contamination
*B) Recent strenuous exercise
C) Early urinary tract infection
D) Analyzing an old specimen

28. Hyaline casts may degenerate into:

A) Granular casts
B) Fatty casts
C) Broad casts
*D) Waxy casts

29. Waxy casts can be found in the urine sediment:

*A) In patients with renal failure
B) Of an alkaline urine
C) Whenever abnormal protein is present
D) When urine is not correctly preserved

30. The urinary sediment constituent most closely associated with bleeding within the nephron is the:
A) RBC
*B) RBC cast
C) WBC cast
D) Hyaline cast

31. All of the following may be seen in the urine following strenuous exercise except:
A) Protein
*B) Glucose
C) Hyaline casts
D) Granular casts
32. To distinguish a cellular cast from a clump of cells, the clinical laboratory scientist should:
A) Check for dysmorphic cells
*B) Look carefully for a cast matrix
C) Determine if free-standing cells are present
D) Examine the sediment using polarizing microscopy

33. All of the following are associated with severe urinary stasis except:
A) Granular casts
B) Waxy casts
*C) WBC casts
D) Broad casts

34. Identification of urinary crystals is based on shape and:

*A) Urine pH and crystal solubility
B) Urine protein and crystal size
C) Urine bilirubin and glucose
D) Urine pH and crystal size

35. Urinary crystals that appear yellow to reddish-brown are:

A) Calcium oxalate
B) Triple phosphate
C) Cholesterol
*D) Uric acid

36. To dissolve amorphous urates, you could:

*A) Warm the specimen to body temperature
B) Add concentrated sodium hydroxide
C) Add dilute hydrochloric acid
D) Add dilute acetic acid

37. Nonpathogenic or “normal” crystals found in acidic urine include:

*A) Calcium oxalate, uric acid, amorphous urates
B) Calcium oxalate, uric acid, sulfonamides
C) Uric acid, amorphous urates, triple phosphate
D) Uric acid, calcium carbonate, bilirubin

38. All of the following crystals can be found in acid urine except:
A) Cholesterol
B) Tyrosine
C) Cystine
*D) Ammonium biurate

39. Abnormal crystals are most frequently seen in a urine that is:
*A) Acid
B) Neutral
C) Alkaline
D) Collected for 24 hours
40. Information that aids in the identification of crystals includes all of the following except:
*A) Urine temperature
B) Urine pH
C) Crystal solubility
D) Crystal birefringence

41. Which of the following crystals occurs in two very distinct forms?
A) Ammonium biurate
*B) Calcium oxalate
C) Leucine
D) Cholesterol

42. Nonpathogenic or “normal” crystals found in alkaline urine include:

A) Calcium oxalate, uric acid, amorphous urates
B) Calcium oxalate, uric acid, sulfonamides
C) Uric acid, amorphous urates, calcium carbonate
*D) Triple phosphate, calcium carbonate, ammonium biurate

43. Crystals found in the urine that are associated with pathogenic disease include:
A) Calcium oxalate and uric acid
*B) Leucine and tyrosine
C) Heavy amorphous phosphates
D) Triple phosphate and ammonium biurate

44. A urine specimen refrigerated overnight is cloudy and has a pH of 6. The turbidity is probably due to:
A) Amorphous phosphates
*B) Amorphous urates
C. Triple phosphate crystals
D. Calcium oxalate crystals

45. All of the following affect the formation of crystals except:

A) Urine specific gravity
B) Urine pH
*C) Urinary casts
D) Urine temperature

46. Which of the following results should have testing repeated?

A) Positive blood and protein
*B) pH 7.0 with uric acid crystals
C) Positive bilirubin and urobilinogen
D) pH 8.0, WBCs, and triple phosphate crystals

47) The significance of seeing bacteria in the urine sediment is increased when:
A) RBCs and casts are present
B) The patient has an elevated temperature
C) The specimen is cloudy
*D) WBCs are present
48. Yeast may appear in the urine sediment in all of the following forms except:
A) Mycelial
*B) Biconcave
C) Oval
D) Budding ovals

49. Motility by which of the following is most noticeable during the urine sediment examination?
A) Spermatozoa
B) Candida albicans
*C) Trichomonas vaginalis
D) Escherichia coli

50. Urine sediment artifacts frequently differ from true sediment constituents by their:
A) Location in the specimen
B) Appearance
*C) Refractility
D) Number present

51. In an unpreserved and old urine specimen, there could be difficulty differentiating between bacteria
and:
A) Yeast
B) Mucus
*C) Amorphous phosphates
D) Pollen grains

52. Which of the following is most likely to be found in the urine of a diabetic patient?
A) Trichomonas vaginalis
B) Escherichia coli
C) Staphylococcus saprophyticus
*D) Candida albicans

53. Specimens containing mucus may be erroneously reported as containing:

A) Bacteria
B) Yeast
*C) Hyaline casts
D) Oval fat bodies

True/False

1. The finding of increased urinary WBCs is not significant unless increased bacteria are also present.
False

2. WBC casts should always be accompanied by significant bacteriuria.

False

3.. To be considered significant, yeast cells in the urine sediment should be accompanied by leukocytes
True

4. Trichomonas vaginalis is not found in urine from male patients.

False