This document discusses urinalysis and urinary sediment examination. It provides details on: 1. The components evaluated in urinalysis including gross evaluation, dipstick analysis, and microscopic examination of urine sediment. 2. Procedures for proper collection and handling of urine samples. 3. The clinical significance of findings from urinary sediment examination such as crystals, cells, casts, and microorganisms. 4. Common urinary sediment profiles associated with kidney diseases including nephrotic syndrome, nephritic syndrome, acute tubular necrosis, and urinary tract infections.

1. ‫الجديد‬ ‫العام‬ ‫المنصوره‬ ‫مستشفى‬(‫الدولى‬)

2. urinalysis
Is a Poor man renal biopsy

3. urinalysis
 one of the key tests to evaluate kidney and urinary
tract disease.
 Dipsticks are the most widely used method for
urinalysis, but the nephrologist should be aware of
their limitations.
 Urine sediment examination is an integral part of
urinalysis, performed routinely in general clinical
laboratories.
 urine microscopy should be performed by trained
nephrologists rather than clinical laboratory personnel

4. urine Composition
urine consists of urea and other organic and inorganic
chemicals dissolved in water.
Urine is normally 95% water and 5% solutes, although
considerable variations in the concentrations of these
solutes can occur owing to the influence of factors such as
dietary intake, physical activity, body metabolism, and
endocrine functions

5. Primary Components in Normal Urine
Component Comment
Urea Primary organic component. Product of protein and amino acid metabolism
Creatinine Product of creatine metabolism by muscles
Uric acid Product of nucleic acid breakdown in food and cells
Chloride Primary inorganic component. Found
in combination with sodium (table salt) and many other inorganic substances
Sodium Primarily from salt, varies by intake
Potassium Combined with chloride and other salts
Phosphate Combines with sodium to buffer the blood
Ammonium Regulates blood and tissue fluid acidity
Calcium Combines with chloride, sulfate, and phosphate

6. urinalysis
Consists of three components:
 Gross evaluation.
 Dipstick analysis.
 M/E the urine sediment

7. OBTAINING THE SPECIMEN FOR
ANALYSIS
 Should be collected into clean dry container.
 Clean the external genitalia
 Provide a midstream specimen for analysis.
 Directly from the catheter tubing to ensure recently
produced urine and to avoid contamination.
 Should be examined at room temperature within two
hours of retrieval
 Refrigerated at 2 to 8 degrees Celsius and then re-
warmed to room temperature

8. Sample 24-Hour (Timed) Specimen
Collection Procedure
 Provide the patient with written instructions, and explain
the collection procedure.
Provide the patient with the proper collection container
and preservative.
Day 1: 7 a.m.: patient voids and discards specimen;
collects all urine for the next 24 hours.
Day 2: 7 a.m.: patient voids and adds this urine to
previously collected urine.
On arrival at laboratory, the entire 24-hour specimen is
thoroughly mixed, and the volume is measured and
recorded.

9. Clean-Catch Specimen Collection: Female
Cleansing Procedure
1. Wash hands.
2. Remove the lid from the container without touching the
inside of the container or lid.
3. Separate the skin folds (labia).
4. Cleanse from front to back on either side of the urinary
opening with an antiseptic towelette, using a clean one for
each side.
5. Hold the skin folds apart and begin to void into the toilet.
6. Bring the urine container into the stream of urine and collect
an adequate amount of urine. Do not touch the inside of the
container or allow the container to touch the genital area.
7. Finish voiding into the toilet.
8. Cover the specimen with the lid. Touch only the outside of
the lid andcontainer.
9. Label the container with the name and time of collection
and place in the specified area or follow institutional policy.

10. Clean-Catch Specimen Collection: Male
Cleansing Procedure
1. Wash hands.
2. Remove the lid from the sterile container without touching
the inside of the container or lid.
3. Cleanse the tip of the penis with antiseptic towelette and
let dry. Retract the foreskin if uncircumcised.
4. Void into the toilet. Hold back foreskin if necessary.
5. Bring the sterile urine container into the stream of urine and
collect an adequate amount of urine. Do not touch the
inside of the container or allow the container to touch the
genital area.
6. Finish voiding into the toilet.
7. Cover the specimen with the lid. Touch only the outside of
the lid andcontainer.
8. Label the container with the name and time of collection
and place in the specified area or follow institutional policy.

11. Urine Clarity
Clarity Term
Clear No visible particulates, transparent
Hazy Few particulates, print easily seen through urine
Cloudy Many particulates, print blurred through urine
Turbid Print cannot be seen through urine
Milky May precipitate or be clotted

12. 1.GROSS ASSESSMENT
Colors

14. Urine Dipstick
• pH 4.8 -8.0 (mean 6.1)
• Osmolality 500-800 mOsm/Kg water
• Specific gravity 1.003-1.030
• Volume 600-2500(Avg 1200ml)
• Organic constituents per 24 Hours
Nitrogenous 25 - 35 gm
Urea 15-30 gm
Creatinine 1 -1.6 gm
Ammonia 0.7(0.3-1) gm
Uric acid 0.45 – (0.3 – 0.6) gm
Protein < 150 mg
Amylase 4-400 U/L

15. Table5–1
Causes of Acid and Alkaline Urine
Acid Urine Alkaline Urine
Emphysema
Hyperventilation
Diabetes mellitus Vomiting
Starvation Renal tubular acidosis
Dehydration Presence of urease- producing bacteria
Diarrhea Vegetarian diet
Presence of acid-producing Old specimens bacteria
(Escherichia coli)
High-protein diet
Cranberry juice
Medications

16. Microscopic Examination
• Crystals
• Micro-organisms0-5 /low power field
Granular ,waxy,
• Broad casts
• Cells And Casts
RBC 0-2 /high power field
WBC 0-2 /high power field
Bladder Cells -ve
Squamous Cells -ve
Tubular cells -ve
Hyaline cast -ve

17. Clinical Significance of Crystals
 Large numbers of uric acid crystals may be associated
with AKI caused by acute urate nephropathy
 large numbers of monohydratedcalcium oxalate
crystals, especially with a spindle shape,may be
associated with AKI from ethylene glycol intoxication

18. Pathologic Crystals
 Cholesterol Crystals Cholesterol crystals are thin,
transparentplates, often clumped together, with sharp
edges
 Cystine Crystals Cystine crystals occur in patients
with cystinuriaand are hexagonal plates with irregular
sides that are oftenheaped on one another . They
precipitate in acid urine.Evaluation of their size can be
used to predict the recurrence ofcystine stones

19. Crystals Caused by Drugs
 especially in drug overdose, dehydration,
hypoalbuminemia ,specific urinary pH favoring drug
crystallization.
 Examples . sulfadiazine, amoxicillin and
ciprofloxacin , acyclovir and indinavir

21. Uric acid crystals. This rhomboid shape is the most common

22. Bihydrated calcium oxalate crystals with typical
“letter envelope” monohydrated calcium oxalate
crystals.

23. Star-like brushite (calcium phosphate) crystal-
Struvite (triple phosphate

24. Cholesterol crystal- Cystine
crystals

25. Dihydroxyadenine crystal
Amoxicillin crystal

26. Microscopic examination : RBCs
 Hematuria if RBCs> 5 cells by HPF
 Persistent hematuria : RBCs>5 on 3 times
 Gross hematuria: RBCs>100 on single analysis
 Non glomerular hematuria if 80% of RBCs with
regular appearance
 Glomerular hematuria if > 80% are dysmorphic and 5%
are acanthocytes

27. • Isomorphic RBCs
• Different types of dysmorphic erythrocytes.
• Different types of acanthocytes .
• Neutrophils with their lobulated nucleus and granular cytoplasm

31.  3. Micro-organisms
• many bacteria …. rods and debris.
• Candida albicans.
• Trichomonas vaginalis .
• Schistosoma haematobium

32. Casts
• Elongated elements with a basic cylindrical
shape that has some possible variation due to
bending, wrinkling, and irregular edges.
• They form within the distal tubules and the
collecting ducts .

33. Casts

34. Clinical Significance of
Urinary Casts
 Hyaline Normal individual; renal disease
 Hyaline-granular Normal individual; renal disease
 Granular Renal disease; acute tubular necrosis
 Waxy Renal disease with function impairment
 Fatty Proteinuria; nephrotic syndrome

35.  Erythrocyte Glomerular hematuria; proliferative/necrotizing GN
 Leukocyte Acute interstitial nephritis; acute pyelonephritis;
proliferative GN
 Renal tubular epithelial cell(so-called epithelial casts)Acute tubular
necrosis; acute interstitial nephritis; proliferative GN; nephrotic
Syndrome
 Hemoglobin Same as for erythrocyte cast; hemoglobinuria
caused by intravascular hemolysis

36.  Myoglobin Rhabdomyolysis
 Bilirubin Jaundice caused by increased direct bilirubin
 Bacterial, fungal Bacterial or fungal infection in the
kidney
 Containing crystals; renalstonedisease;Normal
individual;crystalluricAKI

44. Main Urinary Sediment Profiles
 Nephrotic syndrome(proteinuria:++++) Hallmark Fatty
particles
Associated Findings Renal tubular epithelial cells
(RTECs) RTEC casts Erythrocytes (absent to moderate
number)
Nephritic syndrome(proteinuria:+ → ++++) Hallmark
Erythrocytes(moderate to high number)
Erythrocyte/hemoglobin casts
Associated Findings Leukocytes (low number)RTECs (low
number) RTEC casts Waxy casts

45. Acute tubular necrosis
(proteinuria:absent to trace)
Hallmark RTECs RTEC casts Granular casts
Associated Findings Variable according to causeof ATN
(e.g., myoglobin casts in rhabdomyolysis; uric acid
crystals in acute urate nephropathy; erythrocytes in
proliferative/active glomerulonephritis)

46. Urinary tract infection
 (proteinuria: absent) Hallmark Bacteria Leukocytes--
Associated Findings - Isomorphic erythrocytes
Superficial transitional epithelial cells Struvite crystals
(for infections caused by urease-producing bacteria)
Leukocyte casts (in renal infection)

47.  Urologic diseases (proteinuria: absent)
Hallmark Isomorphic erythrocytes (low to high number)
Leukocytes Associated Findings Transitional cells (deep,
superficial, atypical)
 Polyomavirus BK infection (proteinuria: absent)
Hallmark Decoy cells
Associated Findings Decoy cell casts (in BK virus
nephropathy

48. Urinary
indices
ATN Prerenal
(intact tubules)
Urinary Na+ >40 meq/L <20 meq/L
Fraction
excreation of
Na+ (FE Na+)
>2% <1%

49. urinary sediment
Bland urinary sediment:
• characterized by few cells with little or no
casts +/- proteinuria.
Active urinary sediment :
• characterized by red blood cells with
casts , WBCs and epithelial cells +/-
proteinuria
Bland sediment+
proteinuria
Bland
sediment
Nephrotic
syndrome
with active
sediment
Nephritic
syndrome
Acute
Nephritis
RPGN
Active urinary
sediment+
Nephrotic
range
proteinuria
Active urinary
sediment+non-
Nephrotic range
proteinuria

50. Albumin / creatinine ratio (ACR

51. Clinical Significance of
Urine Protein
1-Prerenal
Intravascular hemolysis
Muscle injury
Acute phase reactants
Multiple myeloma
2-Renal
Glomerular disorders
Immune complex disorders
Amyloidosis Toxic agents
Diabetic nephropathy Strenuous exercise Dehydration
Hypertension
Pre-eclampsia

52. 3-Tubular Disorders
Fanconi syndrome
Toxic agents/heavy metals
Severe viral infections
4-Post renal
Lower urinary tract infections/ inflammation
Injury/trauma
Menstrual contamination
Prostatic fluid/spermatozoa
Vaginal secretions

53. Laboratory Testing in Glomerular Disorders
Disorder Primary Urinalysis
Result
Other Significant
Tests
Acute glomerulonephritis Macroscopic
hematuria
Anti–group A
streptococcal
enzyme tests
BUN
Creati
nine
eGFR
Proteinuria
RBC casts
Granular casts
Rapidly progressive
glomerulonephritis
Macroscopic
hematuria
Proteinuria
RBC casts

54. Laboratory Testing in Metabolic and Hereditary Tubular
Disorders
Disorder Primary Urinalysis
Results
Other Significant
Tests
Acute tubular necrosis Microscopic hematuria Hemoglobin
Proteinuria Hematocrit
Renal tubular epithelial
cells
Renal tubular epithelial
cell casts
Cardiac enzymes
Hyaline, granular, waxy,
broad casts
Fanconi syndrome Glucosuria Serum and urine
electrolytes
Possible cystine crystals Amino acid
chromatography
Uromodulin-
associated kidney
disease (early stages)
Renal tubular epithelial
cells
Serum uric acid
Late stages See chronic
glomerulonephritis
Nephrogenic diabetes
insipidus
Low specific gravity,
polyuria
ADH testing
Renal glucosuria Glucosuria Blood glucose

55. Laboratory Results in Interstitial Disorders
Disorder Primary Urinalysis Results Other Significant Tests
Cystitis Leukocyturia
Bacteriuria
Microscopic
hematuria Mild
proteinuria
Increased pH
Leukocyturia
Bacteriuria
WBC casts
Bacterial
casts
Microscopic
hematuria
Proteinuria
Leukocyturia
Bacteriuria
WBC casts
Bacterial
casts
Granular, waxy, broad casts
Hematuria
Proteinuria
Hematuria
Proteinuria
Leukocytu
ria WBC
casts
Urine culture
Acute pyelonephritis Urine culture
Chronic pyelonephritis Urine
culture
BUN
Creatinine
Acute interstitial nephritis
eGFR
Urine
eosinophils
BUN
Creatini
ne
eGFR

56. Clinical Information Associated With Interstitial Disorders
Disorder Etiology Clinical Course
Cystitis
Acute
pyelonephritis
Chronic
pyelonephritis
Acute interstitial
nephritis
Ascending bacterial infection of
the bladder
Infection of the renal tubules
and interstitium related to
interference of urine flow to
the bladder, reflux of urine
from the bladder, and
untreated cystitis
Recurrent infection of the
renal tubules and
interstitium caused by
structural abnormalities
affecting the flow of urine
Allergic inflammation of the
renal intersti- tium in
response to certain
medications
Acute onset of urinary frequency
and burning resolved with
antibiotics
Acute onset of urinary frequency,
burning, and lower back pain
resolved with antibiotics
Frequently diagnosed in
children; requires correction
of the underlying structural
defect
Possible progression to renal
failure
Acute onset of renal dysfunction
often accom- panied by a skin
rash
Resolves following
discontinuation of medica- tion
and treatment with
corticosteroids

58. References
• Comprehensive clinical nephrology 6th edtion
• Professor doctor/ iman sarahan Ain shams
university
• ESNT VIRTUAL ACADEMY

59. THANK YOU