Urine Analysis (Practical Approach) - Dr. Gawad
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Urine Analysis (Practical Approach) - Dr. Gawad
- 1. Urine Analysis Practical Approach Mohammed Abdel Gawad Nephrology Consultant - Alexandria MD Nephrology - Mansoura University drgawad@gmail.com ESNT Webinar 14, May, 2020
- 2. To download the lecture with full animations contact me drgawad@gmail.com For more Nephrology lectures visit www.NephroTube.com
- 5. Talk Outline • Sample collection • Gross examination • Dipstick • Urine sediments: • Cells • Casts • Crystals • Microorganisms • Interpretation • Clinical Case Scenarios
- 6. Talk Outline • Sample collection • Gross examination • Dipstick • Urine sediments: • Cells • Casts • Crystals • Microorganisms • Interpretation • Clinical Case Scenarios
- 7. 2008 Jun;51(6):1052-67 Second Urine of the Morning preferred to the first urine of the morning (produced overnight) because pro- longed standing of urine in the bladder favors the lysis of urine particles
- 8. In patients with indwelling urinary catheters Urinalysis-approved guideline, 3rd ed. Clinical and Laboratory Standard Institute, 29(4), 2009 Wayne, PA This will ensure that the sample represents recently produced urine and to avoid contamination of the sample by debris in the collection bag
- 9. Alternatively, formaldehyde, glutaraldehyde, and “cell- FIX” (a formaldehyde- based fixative [Becton Dickinson and Company, Erembodegem, Bel-gium]) can be used as preservatives of urine particles. However, preservatives can alter the appearance of particles. If this is not feasible, the sample should be refrigerated at 2 to 8 degrees Celsius and then re-warmed to room temperature prior to assessment (however, this procedure favors precipitation of phosphates or urates) Urine particles can lyse rapidly after collection, thus the specimen should be examined at room temperature within 2-4 hours of retrieval Urinalysis-approved guideline, 3rd ed. Clinical and Laboratory Standard Institute, 29(4), 2009 Wayne, PA
- 10. Talk Outline • Sample collection • Gross examination • Dipstick • Urine sediments: • Cells • Casts • Crystals • Microorganisms • Interpretation • Clinical Case Scenarios
- 11. Talk Outline • Sample collection • Gross examination • Dipstick • Urine sediments: • Cells • Casts • Crystals • Microorganisms • Interpretation • Clinical Case Scenarios
- 12. Gross Assessment - Normal urine • Clear • Light yellow
- 13. Gross Assessment - Abnormal urine • Clear • Light yellow Turbid (cloudy) • Infection • Chyluria • Increased concentration of any urine particle (erythrocytes, leukocytes, bacteria, squamous epithelial cells, or crystals) It must be remembered that pathological samples can be perfectly clear 2008 Jun;51(6):1052-67
- 14. Gross Assessment - Abnormal urine • Clear • Light yellow 2008 Jun;51(6):1052-67 Frothy urine
- 15. Gross Assessment - Abnormal urine • Clear • Light yellow
- 17. South Med J. 2012 Jan;105(1):43-7
- 18. Infection also is the most frequent cause of abnormal pungent odor of urine, which is caused by the production of ammonia by bacteria 2008 Jun;51(6):1052-67
- 19. Talk Outline • Sample collection • Gross examination • Dipstick • Urine sediments: • Cells • Casts • Crystals • Microorganisms • Interpretation • Clinical Case Scenarios
- 20. Talk Outline • Sample collection • Gross examination • Dipstick • Urine sediments: • Cells • Casts • Crystals • Microorganisms • Interpretation • Clinical Case Scenarios
- 23. RBCs (Heme) (pseudoperoxidase) Urine peroxideandachromogen test pad peroxideandachromogen 2008 Jun;51(6):1052-67
- 24. RBCs (Heme) (pseudoperoxidase) Urine peroxideandachromogen test pad peroxideandachromogen Free Hb or free myoglobin Semen Not always RBCs (false +ve) Enterobacteriaciae species, Staph. species, Strept. species 2008 Jun;51(6):1052-67
- 25. RBCs (Heme) (pseudoperoxidase) Urine peroxideandachromogen test pad peroxideandachromogen Free Hb or free myoglobin Semen Not always RBCs (false +ve) diagnosis of hematuria requires confirmation with microscopy Enterobacteriaciae species, Staph. species, Strept. species 2008 Jun;51(6):1052-67
- 26. RBCs (Heme) (pseudoperoxidase) 1992 Mar;38(3):426-31 Urine peroxideandachromogen test pad peroxideandachromogen Not always RBCs (false -ve) Vitamin C
- 28. neutrophils and macrophages Leukocyte esteraseLysis Urine 2008 Jun;51(6):1052-67
- 29. neutrophils and macrophages Leukocyte esteraseLysis Urine • Concentrated urine • High relative density • Proteinuria • Glucosuria • Cephalotine and tetracycline (strong interference) • Cephalexine (moderate interference) • Tobramycin (mild interference) False -ve 2008 Jun;51(6):1052-67 but positive microscopy findings
- 30. neutrophils and macrophages Leukocyte esteraseLysis Urine • Alkaline pH • Low relative density False +ve but negative microscopy findings 2008 Jun;51(6):1052-67
- 33. Enterobacteriaceae species nitrate reductase Urine nitrate nitrite Sensitivity of this test is low, whereas Specificity is greater than 90% • a diet rich in nitrates (vegetables) • sufficient bladder incubation time 2008 Jun;51(6):1052-67
- 35. Most sensitive to albumin and provides a semiquantitative analysis Can not detect: • Albuminuria 30 to 300 mg/day • Very low sensitivity to tubular protein and light chain Igs Diluted urine: underestimate the degree of albuminuria or even a negative dipstick if the urine is very diluted Concentrated urine: overestimate the degree of albuminuria 2008 Jun;51(6):1052-67
- 38. The urine pH ranges from 4.5 to 8, depending upon the systemic acid-base balance • Diagnosis of renal tubular acidosis • Monitoring urine alkalinization in management of rhabdomyolysis and to aid elimination of certain drugs • Kidney stones diagnosis and management
- 39. The urine pH ranges from 4.5 to 8, depending upon the systemic acid-base balance • Diagnosis of renal tubular acidosis • Monitoring urine alkalinization in management of rhabdomyolysis and to aid elimination of certain drugs • Kidney stones diagnosis and management
- 40. The urine pH ranges from 4.5 to 8, depending upon the systemic acid-base balance • Diagnosis of renal tubular acidosis • Monitoring urine alkalinization in management of rhabdomyolysis and to aid elimination of certain drugs • Kidney stones diagnosis and management 2008 Jun;51(6):1052-67
- 41. The urine pH ranges from 4.5 to 8, depending upon the systemic acid-base balance • Diagnosis of renal tubular acidosis • Monitoring urine alkalinization in management of rhabdomyolysis and to aid elimination of certain drugs • Kidney stones diagnosis and management Infection with any pathogen that produces urease → urine pH above 7 to 7.5, even if urinary acidification by the kidney is normal Proteus mirabilis 2008 Jun;51(6):1052-67
- 44. 2002 Jan;323(1):39-42 Urine osmolality is determined by the number of particles
- 45. 2002 Jan;323(1):39-42 Urine osmolality is determined by the number of particles In most clinical settings, the urine osmolality can be measured directly, and estimation using the urine specific gravity is unnecessary
- 47. • DM (renal glucose threshold 180 mg/dL) • Proximal tubular dysfunction • Fanconi syndrome • Isolated renal glycosuria associated with genetic mutations • SGLT-2 inhibitors Nephrol Dial Transplant. 2012;27(12):4273 Ann Intern Med. 2013;159(4):262 N Engl J Med. 2017;377(7):644
- 48. • DM (renal glucose threshold 180 mg/dL) • Proximal tubular dysfunction • Fanconi syndrome • Isolated renal glycosuria associated with genetic mutations • SGLT-2 inhibitors Nephrol Dial Transplant. 2012;27(12):4273 Ann Intern Med. 2013;159(4):262 N Engl J Med. 2017;377(7):644 False-negative results occur in the presence of: • ascorbic acid • bacteria False-positive findings may be observed in the presence of: • oxidizing detergents • hydrochloric acid 2008 Jun;51(6):1052-67
- 52. Talk Outline • Sample collection • Gross examination • Dipstick • Urine sediments: • Cells • Casts • Crystals • Microorganisms • Interpretation • Clinical Case Scenarios
- 53. Talk Outline • Sample collection • Gross examination • Dipstick • Urine sediments: • Cells • Casts • Crystals • Microorganisms • Interpretation • Clinical Case Scenarios
- 54. proliferative glomerulonephritis, RPGN, chronic pyelonephritis, urinary schistosomiasis, 2008 Jun;51(6):1052-67 and in association with leukocytes and bacteria For correct interpretation of the findings, both pH and specific gravity of the sample must be known. Alkaline pH and/or low specific gravity, especially less than 1.010, favor the lysis of erythrocytes and leukocytes, which can cause false-negative results by means of microscopy.
- 55. proliferative glomerulonephritis, RPGN, chronic pyelonephritis, urinary schistosomiasis, 2008 Jun;51(6):1052-67 and in association with leukocytes and bacteria
- 57. 2008 Jun;51(6):1052-67 Consider hematuria to be glomerular when 40% or greater of erythrocytes are dysmorphic and/or 5% or greater of erythrocytes examined are acanthocytes
- 62. proliferative glomerulonephritis, RPGN, chronic pyelonephritis, urinary schistosomiasis 2008 Jun;51(6):1052-67 and in association with leukocytes and bacteria
- 63. Granular cytoplasm and Lobulated nucleus
- 64. Granular cytoplasm and Lobulated nucleus Urinalysis-approved guideline, 3rd ed. Clinical and Laboratory Standard Institute, 29(4), 2009 Wayne, PA
- 65. 2008 Jun;51(6):1052-67 Polymorphonuclear leukocytes with the typical granular cytoplasm and lobated nucleus. Phase contrast microscopy, original magnification ×400. Granular cytoplasm and Multilobulated nucleus
- 66. proliferative glomerulonephritis, RPGN, chronic pyelonephritis, urinary schistosomiasis, 2008 Jun;51(6):1052-67 Urinary neutrophils are commonly associated with bacteriuria. However, if the corresponding urine culture is negative (ie, sterile pyuria), interstitial nephritis, renal tuberculosis, and nephrolithiasis should be considered. N Engl J Med. 2015 Mar 12;372(11):1048-54
- 68. proliferative glomerulonephritis, RPGN, chronic pyelonephritis, urinary schistosomiasis. in massive amounts and in association with leukocytes and bacteria 2008 Jun;51(6):1052-67
- 69. proliferative glomerulonephritis, RPGN, chronic pyelonephritis, urinary schistosomiasis. in massive amounts and in association with leukocytes and bacteria 2008 Jun;51(6):1052-67
- 70. proliferative glomerulonephritis, RPGN, chronic pyelonephritis, urinary schistosomiasis. in massive amounts and in association with leukocytes and bacteria 2008 Jun;51(6):1052-67
- 72. proliferative glomerulonephritis, RPGN, chronic pyelonephritis, urinary schistosomiasis. 2008 Jun;51(6):1052-67 and in association with leukocytes and bacteria
- 73. Large spherical nucleus, thin rim of cytoplasm https://is.muni.cz/do/rect/el/estud/lf/js15/mikroskop/web/pages/leukocyty_en.html
- 74. proliferative glomerulonephritis, RPGN, chronic pyelonephritis, urinary schistosomiasis. 2008 Jun;51(6):1052-67 and in association with leukocytes and bacteria
- 76. 2008 Jun;51(6):1052-67 • Fabry disease • Autosomal dominant polycystic kidney • Acute or chronic interstitial nephritis • Prerenal azotemia Am J Kidney Dis. 1985;5(1):49 Am J Kidney Dis. 1988 Apr;11(4):332-7 Am J Kidney Dis. 1988 Apr;11(4):332-7
- 78. proliferative glomerulonephritis, RPGN, chronic pyelonephritis, urinary schistosomiasis. 2008 Jun;51(6):1052-67
- 79. 2019 Feb;73(2):258-272 renal tubular epithelial cells (RTECs) with a single nucleus
- 81. proliferative glomerulonephritis, RPGN, chronic pyelonephritis, urinary schistosomiasis. and in association with leukocytes and bacteria 2008 Jun;51(6):1052-67
- 82. and in association with leukocytes and bacteria 2008 Jun;51(6):1052-67
- 83. proliferative glomerulonephritis, RPGN, chronic pyelonephritis, urinary schistosomiasis. and in association with leukocytes and bacteria 2008 Jun;51(6):1052-67
- 85. Talk Outline • Sample collection • Gross examination • Dipstick • Urine sediments: • Cells • Casts • Crystals • Microorganisms • Interpretation • Clinical Case Scenarios
- 86. Talk Outline • Sample collection • Gross examination • Dipstick • Urine sediments: • Cells • Casts • Crystals • Microorganisms • Interpretation • Clinical Case Scenarios
- 87. Mucoprotein (Tamm-Horsfall protein) secreted by tubule cells webpath.med.utah.edu
- 88. Mucoprotein (Tamm-Horsfall protein) secreted by tubule cells webpath.med.utah.edu
- 89. 2008 Jun;51(6):1052-67 Due to their limited sensitivity, the absence of RBC casts, particularly in a patient with hematuria and a high pre-test probability, does not rule out a proliferative glomerulonephritis Kidney Int. 1991 Jul;40(1):115-20
- 90. 2008 Jun;51(6):1052-67 Due to their limited sensitivity, the absence of RBC casts, particularly in a patient with hematuria and a high pre-test probability, does not rule out a proliferative glomerulonephritis Kidney Int. 1991 Jul;40(1):115-20 In one study 30% with biopsy-proven acute interstitial nephritis in one study had RBC casts in the urine Am J Kidney Dis. 2012 Aug;60(2):330-2
- 91. Urinalysis-approved guideline, 3rd ed. Clinical and Laboratory Standard Institute, 29(4), 2009 Wayne, PA
- 94. 2008 Jun;51(6):1052-67 The absence of WBC casts should not exclude acute interstitial nephritis or acute pyelonephritis in the presence of a reasonable clinical suspicion. Am J Kidney Dis. 2014;64(4):558
- 100. RTEC cast, with multiple RTECs within the cast matrix 2019 Feb;73(2):258-272 2008 Jun;51(6):1052-67
- 102. They are homogeneous in appearance and are characterized by sharp indentations and darker edges that are more distinct.
- 104. Broad casts are wider than other casts, a characteristic believed to be due to their formation in large dilated tubules with little flow. The presence of broad casts is typically associated with advanced chronic kidney disease.
- 106. Hyaline casts are only slightly more refractile than water and have a transparent, empty appearance
- 112. Coarse granular (hemegranular or muddy brown) cast http://www.hdcn.com/vas.htm more specific for ATN However, the presence of granular casts does not always confirm a diagnosis of ATN because they can be seen with AIN, thrombotic microangiopathy, and other kidney lesions AJKD. 2019 Feb;73(2):258-272
- 116. 2009 Wayne, PA
- 123. Talk Outline • Sample collection • Gross examination • Dipstick • Urine sediments: • Cells • Casts • Crystals • Microorganisms • Interpretation • Clinical Case Scenarios
- 124. Talk Outline • Sample collection • Gross examination • Dipstick • Urine sediments: • Cells • Casts • Crystals • Microorganisms • Interpretation • Clinical Case Scenarios
- 129. Urinary tract infection with a urease-producing organism, such as Proteus or Klebsiella
- 138. Talk Outline • Sample collection • Gross examination • Dipstick • Urine sediments: • Cells • Casts • Crystals • Microorganisms • Interpretation • Clinical Case Scenarios
- 139. Talk Outline • Sample collection • Gross examination • Dipstick • Urine sediments: • Cells • Casts • Crystals • Microorganisms • Interpretation • Clinical Case Scenarios
- 141. Talk Outline • Sample collection • Gross examination • Dipstick • Urine sediments: • Cells • Casts • Crystals • Microorganisms • Interpretation • Clinical Case Scenarios
- 142. Talk Outline • Sample collection • Gross examination • Dipstick • Urine sediments: • Cells • Casts • Crystals • Microorganisms • Interpretation • Clinical Case Scenarios
- 144. Talk Outline • Sample collection • Gross examination • Dipstick • Urine sediments: • Cells • Casts • Crystals • Microorganisms • Interpretation • Clinical Case Scenarios
- 145. Talk Outline • Sample collection • Gross examination • Dipstick • Urine sediments: • Cells • Casts • Crystals • Microorganisms • Interpretation • Clinical Case Scenarios
- 153. NephSap AKI
- 154. NephSap AKI
- 156. Acute pyelonephritis, probably as a consequence of an ascending urinary tract infection http://ar.utmb.edu/webpath/labs/urinlab/urinlab.htm#case1
- 161. Thank You
Editor's Notes
- Blue file: In our experience, urinary infection and contamination caused by genital secretions are the most frequent causes of urine turbidity.
- Blue file: In our experience, urinary infection and contamination caused by genital secretions are the most frequent causes of urine turbidity.
- Blue file: In our experience, urinary infection and contamination caused by genital secretions are the most frequent causes of urine turbidity.
- high concentration of bacteria with pseudoperoxidase activity (Enterobacteriaciae species, Staphylococci species, and Streptococci species).
- high concentration of bacteria with pseudoperoxidase activity (Enterobacteriaciae species, Staphylococci species, and Streptococci species).
- Manufacturers have attempted to allay such concerns through the production of dipsticks that oxidize ascorbic acid, thereby minimizing the risk of false negatives [30]. 30. https://www.ncbi.nlm.nih.gov/pubmed?term=16584061
- high glucose or protein concentrations (20 g/L and 5 g/L [2 g/dL and 0.5 g/dL], respectively)
- high glucose or protein concentrations (20 g/L and 5 g/L [2 g/dL and 0.5 g/dL], respectively)
- However, bacteriuria or frank infection may still be present in the absence of nitrite positivity. This would occur with organisms expressing low levels of nitrate reductase (eg, enterococcus), or when urine dwell time in the bladder is short. This is present in most gram-negative uropathogenic bacteria, but is low or absent in others, such as Pseudomonas species, Staphylococcus albus, and Enterococcus species.
- However, bacteriuria or frank infection may still be present in the absence of nitrite positivity. This would occur with organisms expressing low levels of nitrate reductase (eg, enterococcus), or when urine dwell time in the bladder is short. This is present in most gram-negative uropathogenic bacteria, but is low or absent in others, such as Pseudomonas species, Staphylococcus albus, and Enterococcus species.
- A patient with a persistently positive dipstick test for protein should have albuminuria quantified with assessment of the albumin-to-creatinine ratio on a random (spot) urine sample or with a 24-hour urine collection. Recent exposure to iodinated radiocontrast agents can induce transient albuminuria [31]. However, this may not be observed with newer non-ionic contrast agents [32] https://www.uptodate.com/contents/urinalysis-in-the-diagnosis-of-kidney-disease/abstract/31 https://www.uptodate.com/contents/urinalysis-in-the-diagnosis-of-kidney-disease/abstract/32 The dipstick is insensitive to non-albumin proteins, most notably potentially nephrotoxic immunoglobulin light chains. A screen for the presence of such proteins may be performed with the sulfosalicylic acid test.
- A patient with a persistently positive dipstick test for protein should have albuminuria quantified with assessment of the albumin-to-creatinine ratio on a random (spot) urine sample or with a 24-hour urine collection. Recent exposure to iodinated radiocontrast agents can induce transient albuminuria [31]. However, this may not be observed with newer non-ionic contrast agents [32] https://www.uptodate.com/contents/urinalysis-in-the-diagnosis-of-kidney-disease/abstract/31 https://www.uptodate.com/contents/urinalysis-in-the-diagnosis-of-kidney-disease/abstract/32 The dipstick is insensitive to non-albumin proteins, most notably potentially nephrotoxic immunoglobulin light chains. A screen for the presence of such proteins may be performed with the sulfosalicylic acid test.
- Diet affect urine pH
- Klebsiella
- - The osmolality of the urine can be inferred by measuring the urine specific gravity, which is defined as the weight of the solution compared with the weight of an equal volume of distilled water - The urine specific gravity generally varies with the osmolality, rising by approximately 0.001 for every 35 to 40 mosmol/kg increase in urine osmolality Thus, a urine osmolality of 280 mosmol/kg (which is isosmotic to normal plasma) is usually associated with a urine specific gravity of 1.008 or 1.009.
- When present in the urine, glucose triggers the production of peroxide, which in turn leads to the oxidation of a chromogen in a reaction catalyzed by peroxidase [2]. As is the case with the dipstick test for heme, ascorbic acid can produce a false-negative test for glycosuria [29]. https://www.uptodate.com/contents/urinalysis-in-the-diagnosis-of-kidney-disease/abstract/2 https://www.uptodate.com/contents/urinalysis-in-the-diagnosis-of-kidney-disease/abstract/29
- Crenated = the shrunken, notched appearance of a red blood cell, as when exposed to extremely salty solutions RBCs that have membrane protrusions (ie, acanthocytes) are a readily definable subset of dysmorphic RBCs (picture 3A-B) that have a sensitivity of 52 percent and specificity of 98 percent for the diagnosis of glomerulonephritis [47] https://www.uptodate.com/contents/urinalysis-in-the-diagnosis-of-kidney-disease/abstract/47 acanthocytes (also known as G1 cells): a ringshaped body with 1 or more protruding blebs of variable shape and size
- Blue article: Lipids appear as spherical, translucent, and yellow drops of different size. They can be free in urine, either isolated or in clumps, or within the cytoplasm of RTECs or macrophages (the so-called oval fat bodies), or within the matrix of casts (fatty casts). Under polarized light, lipid drops appear as “Maltese crosses” (Figs 2B and 17 online). UpToDate: Lipid droplets, composed primarily of cholesterol esters and, to a lesser degree, cholesterol.
- Blue article: Lipids appear as spherical, translucent, and yellow drops of different size. They can be free in urine, either isolated or in clumps, or within the cytoplasm of RTECs or macrophages (the so-called oval fat bodies), or within the matrix of casts (fatty casts). Under polarized light, lipid drops appear as “Maltese crosses” (Figs 2B and 17 online). UpToDate: Lipid droplets, composed primarily of cholesterol esters and, to a lesser degree, cholesterol.
- Urinary casts are formed only in the distal convoluted tubule (DCT) or the collecting duct (distal nephron). The proximal convoluted tubule (PCT) and loop of Henle are not locations for cast formation. Casts are cylindrical structures that are formed in the tubular lumen; several factors favor cast formation: urine stasis, low pH, and greater urinary concentration https://www.uptodate.com/contents/urinalysis-in-the-diagnosis-of-kidney-disease/abstract/2
- In one study, 6 of 21 patients (nearly 30 percent) with biopsy-proven acute interstitial nephritis in one study had RBC casts in the urine [55]. This implies that RBCs which extrude into the renal tubules from an inflamed interstitium can also lead to cast formation
- White blood cell (WBC) casts are indicative of interstitial or, less classically, glomerular inflammation
- In a biopsy series of patients with confirmed acute interstitial nephritis, only 3 percent of patients had WBC casts in their urine sediment.
- White blood cell (WBC) casts are indicative of interstitial or, less classically, glomerular inflammation
- Waxy casts are thought to be the last stage in the degeneration of a granular cast.
- Hyaline casts may be observed with small volumes of concentrated urine or with diuretic therapy and are generally nonspecific.
- Waxy casts are thought to be the last stage in the degeneration of a granular cast.
- In a biopsy series of patients with confirmed acute interstitial nephritis, only 3 percent of patients had WBC casts in their urine sediment.
- In a biopsy series of patients with confirmed acute interstitial nephritis, only 3 percent of patients had WBC casts in their urine sediment.
- Muddy brown casts of ATN are also known as heme-granular casts. There is likely some staining of the cast by hemoglobin released in to the urine when red cells leak in to the renal tubule as a response to injury.
- In a biopsy series of patients with confirmed acute interstitial nephritis, only 3 percent of patients had WBC casts in their urine sediment.
- calcium oxalate crystalluria may be associated with acute renal failure from ethylene glycol intoxication, some drugs, or ingestion of the exotic star fruit. Calcium oxalate crystals, which are not dependent upon the urine pH….!!!!!!!
- calcium oxalate crystalluria may be associated with acute renal failure from ethylene glycol intoxication, some drugs, or ingestion of the exotic star fruit. Calcium oxalate crystals, which are not dependent upon the urine pH….!!!!!!!
- Magnesium ammonium phosphate (struvite) and calcium carbonate-apatite are the constituents of struvite stones Normal urine is undersaturated with ammonium phosphate. Struvite stone formation occurs only when ammonia production is increased and the urine pH is elevated, which decreases the solubility of phosphate. Both increased ammonia production and increased urine pH occur only in the setting of a urinary tract infection with a urease-producing organism, such as Proteus or Klebsiella.
- Bacteria are often seen in the urine, although the clinical significance of bacteriuria is generally guided by patient symptoms Fungi are also frequently present