Urinalysis and Body Fluids CRg Unit 2; Session 2 RBCs in the Urine Microscopic

Microscopic Sediment – Red Blood Cells Pathological finding - cannot appear in filtrate if nephron is intact. result of damage / injury to glomerular membrane, or urinary tract (inc. renal calculi) Isomorphic / fresh looking RBCs usually come from lower tract Dysmorphic / oddly shaped RBCs been subjected to effects of urine environment longer. Many RBCs and a squamous epithelial cell, low power magnification / lpf The picture in this slide comes from Lippincott Williams & Wilkings, the publishers of the Graff Textbook of Urinalysis and Body Fluids. This is how the RBCs would look under low power magnification - abbreviated lpf.

Microscopic Sediment – Red Blood Cells differentiate: Hemoglobinuria – free hemoglobin in urine Hematuria – presence of increased numbers of intact RBCs in urine Hemosiderin – orange/ brown pigment found as intracellular granules

Microscopic Sediment – Red Blood Cells Although NV = 0-2 hpf, an occasional RBC is more significant than occasional WBC. American Urological Association defines clinical significant microscopic hematuria as: three or more RBC / hpf in 2 of 3 properly collected urine samples.

Microscopic Sediment – Red Blood Cells NV = 0-2 / hpf

Microscopic Sediment – Red Blood Cells Detection High power magnification Reduced light yellow - red sheen (sometimes blue-green) Usually highly retractile, Use fine adjustment knob In dilute or alkaline urine appear as ghost or shadow cells Can be any shape Normal disc Dysmorphic swollen or crenated .

Microscopic Sediment – Red Blood Cells RBCs of various shapes & different levels of magnification

Microscopic Sediment – Red Blood Cells RBC can even get small ‘blebs’ on them, making them appear similar to budding yeast.

Microscopic Sediment – Red Blood Cells Urine RBCs can be easily confused with: WBCs Generally larger Contain nucleus Do not lyse in 2 % acetic acid

Microscopic Sediment – Red Blood Cells Urine RBCs can be easily confused with: Yeast Generally refract light differently Usually have buds / and often are more egg shaped Sometimes demonstrate branching Do not dissolve in 2% acetic acid Do not stain with eosin

Microscopic Sediment – Red Blood Cells Urine RBCs can be easily confused with: Bubbles or oil droplets Large variation in size. Even more refractive / and have ‘hard’ appearing edges. Confirmation?– test for hemoglobin - by dipstick, which is most sensitive to free hemoglobin, rather than intact RBCs

Microscopic Sediment – Red Blood Cells RBC or yeast cell? So here is a quiz slide. Look at all the cells and other sediment in this slide. Now look at the cells at the end of the pointers – are they RBCs, Yeast cells, or one of each? Take a moment to study this slide – how would you want to call this?

Microscopic Sediment – Red Blood Cells RBC or yeast cell? What did you decide ? When I look at this slide, I see some wbcs near the center and at the bottom of the slide… there may be a couple of squamous epithelial cells also at the bottom (@ 6 oclock) There are 5-7 RBCs throughout , Then there those cells in question. First a disclaimer: We are at a disadvantage when evaluating microscopic slides in a powerpoint or a kodochrome slide – we cannot adjust the fine focus knob – something I would want to do - so I could see the depth of these cells and compare them to others in the sediment. My answer? With just this slide frame and without ability to change the focus, I would call both of these RBCs – and here is my reasoning: Both of these cells have the same coloring and are refracting or bouncing the light the same, Yes the cell at the bottom is oval and it appears to have some yeast-like characteristics But – it is the only one in the field that looks this way – a patient with a yeast infection would usually have a larger number of cells to look at. And that little blob at the bottom of that cell can be a bleb – or artifact caused from the urine environment. If in doubt, you must lean to the normal – that is to say – don’t jump to pathology, unless you have sound proof to back you up.

Microscopic Sediment – Red Blood Cells yeast Here is another view of yeast cells, and a WBC at the bottom. This slide came from one of your reference textbooks – Urinalysis and Body Fluids, 5th edition -authored by Susan Strasinger and Marjorie Di Lorenzo.

RBCs (cont’d) Air Bubble Oil Droplets

Microscopic Sediment – Red Blood Cells Viewed on high dry ; 0-2 /hpf Damage anywhere in the urinary tract No nuclei; Yellow-greenish & biconcave / hourglass - if on edge Swollen or Ghosts if in hypotonic or alkaline urine Crenated if in hypertonic urine Can be confused with WBCs Yeast Oil dropplets Air bubbles