Microscopic Examination of Urine Final PDF

Preview

Summary

Microscopic Examination
Discussed by: Ms. Pauline Joen Cuevazs, RMT
...

Description

Microscopic Examination Discussed by: Ms. Pauline Joen Cuevazs, RMT Microscopic Examination of Urine -

Done to detect and to identify insoluble materials present in urine Blood, Kidney, Lower Genitourinary tract, External contaminations o Formed Elements: -

RBC WBC Epithelial Cells Casts Bacteria

- Yeast - Parasites - Mucus - Spermatozoa - Crystals and Artifacts

Urine Sediment Constituents

Red Blood Cell

White Blood Cell

Information - Smooth, non-nucleated, biconcave disk approximately 7mm in diameter o Hypersthenuric Urine: - Crenated or Irregularly shaped o Hyposthenuric Urine: - Swell and lyse rapidly called as Ghost Cells

Larger than RBC, 12mm in diameter Predominant WBC: Neutrophil – contains Granules and Multilobed Nuclei Edemic leukocytes in hypotonic urine – swelling – granules will exhibit Brownian movement; Glitter cells – –WBC that are swollen in hypotonic urine Diluted Alkaline Urine: - Lysis of Neutrophil Hypotonic Urine: - Swelling of Neutrophil “Glitter Cells” – prominent granules

o o

o

o o o

Eosinophil

-

Primarily associated with druginduced interstitial nephritis Preferred stain: Hansel Stain

Sources of Error - Yeast Cells To diffe differentiate: rentiate: Steinheimer Malbin wouldn’t stain yeast [calcium oxalate] - Oil Droplets & Air Bubbles To diffe differentiate: rentiate: variation in size; uniformity in appearance and has high refractive index -

Yeast Cells Oil Droplets Air Bubbles

Correlations - Color Macroscopic: Red color of sediment lysed red blood cells: (+) Chemical test (-) Microscopic exam ascorbic acid interfe interference rence (-) Chemical test (+) Microscopic exam -

Identification & R Reporting eporting HPF Average no. seen in 10 HPF NORMAL: 0-3/HPF RBCs/uL 0-12/HPF RBCs/uL

Reagent Strips

Leukocyte Esterase Nitrite Specific Gravity pH Macroscopic: Cloudy and sediment is gray and white Ly sis integration: (+) Chemical examination (-)Microscopic examination Presence of lymphocyte: (-) Chemical exam (+)Microscopic exam

 Differentiation from neutrophils in routine exam is impossible  Has azurophilic granules = Should be (+) leukocyte

-

HPF Average no. seen in 10 HPF

NORMAL: 0-8/HPF WBCs/uL 10 WBCs/uL

Clinical Significance Macroscopic Hematuria: Frequently associated with advanced glomerular damage and also seen in damage to the vascular integrity of genitourinary tract, acute infection or inflammation and coagulation disorders. Strenuous Exercise: RBCs Hyaline May be seen Granular RBC Cast False positive positive: vaginal secretion & hemorrhoids Pyuria: -

Increase White Blood Cells in urine

Bacterial infections: - pyelonephritis - cystitis - urethritis - prostatitis Nonbacterial infections: - nephritis - glomerulonephritis - chlamydia -mycoplasmosis - tuberculosis - trichomonads and mycoses. -

>1% Eosinophil Acute Interstitial Nephritis (AIN) occasionally, Chronic Urinary Tract

infections (UTIs)

Microscopic Examination Discussed by: Ms. Pauline Joen Cuevazs, RMT

Lymphocyte

Monocytes & Macrophages

esterase  Has no azurophilic granules = Should be (-) leukocyte esterase

Preferred stain: Wright’s Stain Papanicolau’s Stain

 Has azurophilic granules = Should be (+) leukocyte esterase

-

Single large nucleus that is round to oval Irregular kidney shaped nuclei & abundant cytoplasm Preferred Stain: Stain:Wright’s Stain Papanicolau’s Stain

-

Bacterial Infections Lupus Erythematosus Glomerulonephritis Inerstitial Nephritis Tumors

Epithelial Cells

-

Derived from linings of the genitourinary system Normal cell turnover of aging cells Epithelial damage caused by inflammation or Renal disease

Squamous Epithelial Cells

Transitional (Urot (Urothelial) helial) Epithelial Cells

Information Largest cell found in the urine Thin, Flagstone-shaped cells contains abundant, irregular cytoplasm and prominent nucleus Most common contaminant in female urine o Due Cell: - squamous epithelial cell covered with Gardnerella vaginalis Smaller in squamous epithelial cells Appear in several forms including spherical, polyhedral and caudate with centrally located nuclei a. Superficial layer layer- larger, round, pear shaped b. Intermediate llayer ayer ayer- round but smaller c. Deep Basal layer – elongated / columnar-like -

-

Renal T Tubular ubular Epi Epithelial thelial Cells

PCT

Sources of Error Rarely encountered Folded cells may resemble casts

Correlations Clarity

Identification & R Reporting eporting Clinical Significance LPF - The ONLY epithelial cell Rare, Few, Moderate, assessed using LPO Many No diagnostic significance

-

Spherical forms resembles RTE cells

-

Clarity Blood if malignancy associated

-

HPF Rare, Few, Moderate, Many

-

Spherical

-

Leukocyte Esteracse

-

HPF

-

Increased in UTI Clusters or sheets seen after catheterization

Urologic Procedure [Catheterization]: - increased transitional cells in singly, in pairs, or in clumps (syncytia) Malignancy/Vir Malignancy/Viral al Infx: - Transitional cells with vacuoles and irregular nuclei -

>2 RTE/HPF is

Microscopic Examination Discussed by: Ms. Pauline Joen Cuevazs, RMT -

Largest RTE Rectangular Referred to as columnar or convoluted cells

DCT -

-

Smaller than those from PCT Round or Oval

CD

forms of Transitional cells Granular casts Spindle form RTE – after regeneration of cell

-

Nitrite (Pyelonephritis) Color Clarity Protein Bilirubin (Hepatitis) Blood

-

Average no. per HPF

Clarity Blood Free Fat Droplets/ Fatty Casts

-

HPF Average no. per HPF

considered signiicant

-

Oval F Fat at Bodies

Cuboidal- never round Appear in groups of Three or more called Renal Fr Fragments agments o Necrosis of Renal T Tubules ubules - increased RTE cells Ex: - Exposure to heavy metals - Drug- induced Toxicity - Viral Infx - Malignant infiltrations - Salicylate poisoning - Acute allogenic transplant rejection Preferred Stain: Prussian Blue Stain Highly refractile, nucleus may be difficult to observe Seen in: Severe tubular necrosis Diabetes Mellitus Trauma cases (release of bone marrow fat from long bones o Bubble Cells: - endoplasmic reticulum has dilated prior to cell death Preferred Stains: Sudan III Oil Red - O

-

Confirm with fat stains and polarized microscopy

-

-

Microscopic Examination Discussed by: Ms. Pauline Joen Cuevazs, RMT

TECHNIQUE Bright field microscopy Phase contrast microscopy

Polarizing microscopy Dark field microscopy Fluorescence microscopy

Interference contrast

FUNCTION Used for routine urinalysis Most commonly used Enhances visualization of elements with low refractive indices, such as hyaline casts, mixed cellular casts, mucous threads and Trichomonas Aids in identification of cholesterol(maltese cross formation) in oval fat bodies, fatty casts and crystals Aids in identification of Treponema pallidum Allows visualization of naturally fluorescent microorganism or those stained by a fluorescent dye including labeled antigens and antibodies Produces a 3D microscopy image and layer-by-layer imaging of specimens -Hoffman Hoffman Hoffman: Modulation content -Romanowski -Romanowski: differential contrast

Microscopic Examination Discussed by: Ms. Pauline Joen Cuevazs, RMT

RBC CD RTE Eosinophil

WBC SquamousPCT Epithelial RTE Cells

Lymphocyte Myeline Filaments Formation Squamous Epithelial Cells Spindle form RTE Transitional Epithelial Cells

orre B

Yeasts

in Non- Pat Pathologic: hologic: - Few bacteria are usually present as a result of Vaginal Urethra, External Genitalia, or Collectioncontainer contamination Pathologic: - Pyelonephritis Visualization: Phase Microscopy Unacceptable Specimen: Urine Specimen @pH 8.0/9.0 Cytocentrifugation: - If turbid – Increase Bacteria - Refractile oval structures that may or may not contain a bud Growth of Y Yea ea east st = Acidic Urine Glucose present = Increase multiplication of Yeast

Par Parasites asites

Trichomonas vvaginalis aginalis – most frequently seen parasite in the urine

-

Nitrite Leukocyte Esterase WBCs

o RBCs To Diff: RBCs can be dissolved in Acetic acid while Yeast cannot

-

Glucose Leukocyte Esterase WBCs

o WBCs o RTE cells o Transitional Cells

-

Leukocyte Esterase WBCs

o

Amorphous Phosphates

nif - Multiplication of bacteria in urine is due to improperly stored urine (stored at room temperature for extended period of time)

Possible In Infx: fx: - May be due to Candida albicans : Seen in Diabetec, Immunocompromised patients, Pregnants and Women with Vaginal moniliasis



Few, Moderate, Many

 

HPF Rare, Few, Moderate, Many

 

HPF Rare, Few, Moderate, Many

Microscopic Examination Discussed by: Ms. Pauline Joen Cuevazs, RMT

Schistosoma haematobium – seldom seen, associated in Bladder cancer in other countries Ova of Entero Enterobius bius vermicularis – considered as Contaminant Visualizaion: Phase Microscopy - Oval, Slightly tapered heads and long , flagella-like tails

Spermatozoa

- Protein material produced by the gland and epithelial cells of the lower genitourinary tract and RTE cells - Thread –like structures with low refractive index Major Constituent: Uromodulin (Tamm- Horsfall Protein)

Mucus / Mucus threads

o

None

-

o

Hyaline Casts

-

CASTS -

Only elements found in the urine that are unique to the kidney.

-

They are formed within the lumens of the DCT and CD Cylinduria: presence of Urinary casts

Identification and Reporting: LPF, Average number seen in 10LPFs HPF, for further Identification CAST COMPOSITION AND FORMA FORMATION TION -

Major constituent of cast is Uromodulin – secreted by RTE cells from DCT and CD.

-

Proteins such as Albumin and Immunoglobulins are also incorporated in the cast matrix.

Normal Conditions: Uromodulin is secreted at constant rate Stress and Exercise: Increase secretion of Uromodulin Factors that enhance Cast Formation: -

Acid pH – duration of protein & precipitation of solute

-

Increase Solute Concentration

-

Urine Stasis – slow urine flow - due to contraction and abnormalities

-

Increase Plasma Proteins (particularly Albumin)

Protein -due to albumin present in semen None

- No clinical significance



Present , based on laboratory protocol

 

LPF Rare, Few, Moderate, Many

Microscopic Examination Discussed by: Ms. Pauline Joen Cuevazs, RMT Athletic Pseudonephritis – increase Albuminuria - due to exercise induced glomerular permeability changes



1.

Aggregation of Uromodulin protein into individual protein 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

Wrinkled and Convoluted (Older Hyaline Casts): Dehydration of Protein fibrils

Casts could be Tapered: Formation at the junction of ALH and DCT Width of the cast depends on the Size of the Tubule in which it is formed

Hyaline Casts

Informations - Most frequently seen cast, which consist almost entirely uromodulin Appearance: - Colorless in unstained sediment and refractive index - Parallel sides - Rounded ends - Cylindrical form Increase Hyaline Cast: NON- Pathologic: - Strenuous exercise - Dehydratiom - Heat exposure - Emotional stress Pathologic: - Acute Glomerulonephritis - Pyelonephritis - Chronic Renal Disease

Sources of Error Mucus Fibers Hair Increase lighting

Correlation - Protein - Blood (Exercise) - Color (Exercise)

Stain Sternheimer Malbin: - Stain cast as Polar Pink

Reporting  LPF  Average number seen in 10 LPFs

Microscopic Examination Discussed by: Ms. Pauline Joen Cuevazs, RMT - Congestive Heart Failure Wa Waxy xy Casts

-

Appearance: - Colorless, Gray or Yellow in unstained urinary sediments - has Brittle, highly refractile cast matrix - often appears Fragments with Jagged ends and have notches in their sides - “Ground Glass” appearance

-

Fibers Fecal Material

Protein Cellular Cast Granular Cast WBCs RBCs

 

LPF Average number seen in 10 LPFs

CELLULAR INCLU INCLUSION SION CASTS

Red Blood Cell Cast

White Blood Cell Casts

Renal T Tubular ubular Cell Cast

Information Appear Appearance: ance: - Orange-Red color - more fragile than other casts. - may exist as fragments or have more irregular shape as the result of tightly packed cells adhering to the protein matrix Greater Stasis of Urine Flow: - more homogenous appearance, retains the orange color characteristic Massive Hemoglobinuri Hemoglobinuria a or Myoglobinuria: - homogenous orange-red or brown casts - granular, dirty, brown cast may be present Visualization: Phase Microscop Visual Phase Microscopy Informations - Composed of Neutrophil Appear Appearance: ance: - may appear granular and multilobed nuclei may be present - Irregular borders may appear due to tightly packed WBCs - Signifies infection or inflammation within the nephron - Most frequently associated with Pyelonephritis (upperUTI) - WBC Cast - WBC with Bacteria - May be present in Acute Inters Interstitial titial Nephritis - WBC Cast - WBC without Bacteria - May accompany RBC Casts in Glomerulonephritis - Cells visible in the cast matrix are smaller, round and oval. (Difficult to differentiate from WBCs)

Sources of Error WBC Clumps

-

WBC Casts

-

Sources of Error RBC Clumps

Stain

Reporting  LPF  Average number seen in 10 LPFs

Correlation - Protein - Leukocyte Esterase - WBCs

Stain  Eosinophil Cast - Hansel Stain - Wright Stain

Reporting  LPF  Average number seen in 10 LPFs

-

Supravital Stain: - use to differentiate RTE

Protein RTE Cells

-

Correlation RBCs Blood Protein

 

LPF Average number seen in 10 LPFs

Microscopic Examination Discussed by: Ms. Pauline Joen Cuevazs, RMT cell Cast from WBCs - Represent the presence of advanced tubular destruction, producing Urinary Stasis along with disruption of the tubular linings - Associated with Heavy metals and Chemical or Drug –induced toxicity, Viral Infections and Allograft rejection.

Mixed Cellular Cast

- They also accompany WBC casts in cases of Pyelonephritis. Hepatitis: - Bilirubin-stained RTE Cells/ Bile-Stained RTE Cells Visualization: Phase Microscopy Interference Contrast Microscopy - Most frequently encountered include RBS and WBC casts in Glomerulonephritis and WBC and RTE Cell Casts

-

WBC and Bacterial Casts in Pyelonephritis

-

Staining and Microscopy aids in Identification



Laboratory Protocol should be followed

CASTS with INCLUSIONS Bacterial Casts

Granular Casts

Fatty Cast Castss

Informations - Containing Bacilli both within and bound to the protein matrix seen in Pyelo Pyelonephritis nephritis - May be Pure Bacterial Casts or Mixed with WBCs

Appearance: - Coarse and Fine granules in a cast matrix Coarse Gr Granular anular Casts Casts: - Disintigration of Cellular cast - Seen in conjunction of WBC casts Fine Granular Ca Casts: sts: - Due to secretion of Lyosomes by RTE Cells - Normally seen Strenuous Exercise: - Increase Granular casts that accompany the Increase Hyaline Cast - Pyelonephritis - Gr Granulonephritis anulonephritis Fat droplets and Oval fat bodies attached to protein matrix and are highly refractile

Sources of Error - Granular Casts

- Clumps of Small Crystals - Columnar RTE Cells

- Fecal debris

Correlation WBC Casts WBCs Leukocyte Esterase Nitrite Protein Bacteria Protein Cellular Casts RBCs WBCs

-

Protein Free fat droplets

Staining - Gram Staining

-

OIO Sudan III

TAG Neutral Fat

Reporting  LPF  Average number seen in 10 LPFs

 

LPF Average number seen in 10 LPFs

 

LPF Average number seen

Microscopic Examination Discussed by: Ms. Pauline Joen Cuevazs, RMT -

Broad Casts

Most frequently associated with Nephrotic Syndrome Also seen in - Toxic T Tubular ubular Necrosis - Diabetes Mellitus - Crush Injuries

Visualization: Polarizing Microscopy Wider than Normal Cast Matrix Often referred to as “ RENAL F FAILURE AILURE CAST” and represent extreme Urine stasis -

All Types of Casts may occur in the broad form, but commonly seen in broad casts are Granular and Waxy

-

Bile-Stained Casts may be seen

-

Oval fat bodies

in 10 LPFs

Orange

- Fecal Material - Fiber

-

WBCs RBCs Granular Casts Waxy Casts

 

LPF Average number seen in 10 LPFs

Microscopic Examination Discussed by: Ms. Pauline Joen Cuevazs, RMT URINARY CRYST CRYSTALS ALS -

Crystals frequently found in the urine are rarely of clinical significance.

-

Primary reason for identification of urinary crystals : - to detect the presence of relatively abnormal types that may represent such disorders as : - Liver Disease - Inborn errors of metabolism - Renal Damage – caused by crystallization of medications compounds within the tubules

Identification and Reporting: 

Normal Crystals: HPF; Rare, Few, Moderate, Many



Abnormal Crystals: may be averaged and reported per LPF

Crystal F Formation: ormation: -

Formed by precipitation of urine solutes, including inorganic salts, organic compounds, and medication (Iatrogenic Compound)

-

Precipitation is subject to changes in temperature, solute concentration and pH, which affect solubility.

-

In general, Organic and Iatrogenic compounds crystalize more easily in acid pH, whereas Inorganic sal...