1. Urine Sediment Case Studies
By Heidi Hanes

2. How to use macroscopic results for possible urine sediment
pH – help decide what type of crystal
Hemoglobin- detect RBC intact and lysed
Leukocyte Esterase – detect WBC
Nitrite – bacteria
Protein – cast, epithelium cells
For any specimen you should use the patient history if known and the results of the urine dipstick chemistries.
Different crystals are seen at either alkaline, acid and/or neutral pH. Acidic crystals include Amorphous Urates, Bilirubin, Calcium Sulfates, Cholesterol, Cystine, Leucine, Sodium Urate, Sulfonamides, Tyrosine, Uric Acid, X-ray dye.
Alkaline Crystals include Amorphous Phosphates, Calcium Carbonates, Calcium Phosphates and Triple Phosphates.
Cyrstlas that can show up in acidic but may be seen in alkaline are Calcium Oxalates and Hippuric Acid. Those that show up in alkaline but can show up in acid is Ammonium Biurate.
Positive Hemoglobin can indicate either intact RBC or lysed RBCs in the urine.
Leukocytes Esterase detect WBC
Nitrites can indicate bacterial infection
Proteins can indicate the present of cast or epithelium cells

3. Case Study

4. Case 1
This is a sample from 35 year old female as part of a routine exam. Laboratory data include:
Specific Gravity
pH – 7.0
Ketones – negative
Glucose – negative
Protein – negative
Blood – negative
Nitrite – negative
Leukocyte esterase – negative
Identify the arrowed object

5. Case 2
This urine sample is from a 35 year old female as part of a routine exam. Laboratory data include:
Specific gravity = 1.015
pH = 7.0
Ketones = negative
Glucose = negative
Protein = negative
Nitrite = negative
Leukocyte esterase = negative
Identify the arrowed object

6. Case 3 Urine sample from a 71 year old male. Laboratory data include:
Specific gravity = 1.015
pH = 6.0
Ketones = negative
Glucose = negative
Protein = negative
Nitrite = negative
Leukocyte esterase = negative
Identify the arrowed object

7. Case 4
This urine sample is from a 60 year old male with history of kidney nephritis. Laboratory data include:
Specific gravity = 1.018
pH = 5.5
Ketones = negative
Glucose = negative
Protein = positive
Nitrite = positive
Blood = positive
Leukocyte esterase = positive
Identify the arrowed object

8. Case 5
This urine sample is from a 60 year old male with history of kidney stones. Laboratory data include:
Yellow and cloudy
Specific gravity = 1.020
pH = 5.5
Ketones = negative
Glucose = negative
Protein = positive
Nitrite = negative
Blood = positive
Leukocyte esterase = positive
Birefringence - absent
Identify the arrowed object

9. Case 6
This urine sample is from a 60 year old male with history of kidney stones. Laboratory data include:
Yellow and cloudy
Specific gravity = 1.020
pH = 5.5
Ketones = negative
Glucose = negative
Protein = positive
Nitrite = negative
Blood = positive
Leukocyte esterase = positive
Birefringence - absent
Identify the arrowed object

10. Case 7
This urine sample is from a 54 year old male routine exam. Laboratory data include:
Specific gravity = 1.015
pH = 7.1
Ketones = negative
Glucose = negative
Protein = negative
Nitrite = negative
Blood = negative
Leukocyte esterase = negative
Birefringent positive
Identify the arrowed object

11. Case 8
This urine sample is from a 12 year old female evaluated for kidney disease Laboratory data include:
Specific gravity = 1.010
pH = 6.0
Ketones = negative
Glucose = negative
Protein = positive
Nitrite = negative
Blood = positive
Leukocyte esterase = positive
Identify the arrowed object

12. Case 9
This urine sample is from a 12 year old female evaluated for kidney disease Laboratory data include:
Specific gravity = 1.010
pH = 6.0
Ketones = negative
Glucose = negative
Protein = positive
Nitrite = negative
Blood = positive
Leukocyte esterase = positive
Identify the arrowed objects

13. Case 10
This urine sample is from a 48 year old male history of diabetes mellitus, edema and new onset renal failure. Laboratory data include:
BUN = 35 mg/dl (serum)
Creatinine = 2.8 mg/dl (serum)
Specific Gravity = 1.007
pH = 7.0
Glucose = positive (4+)
Protein = positive (2+)
Identify the arrowed object

14. Case 11
This urine sample is from a 45 year old male history of diabetes mellitus, edema, hypertension and new onset renal failure. Laboratory data include:
Opalescent urine
Specific Gravity = 1.011
pH = 6.5
Glucose = positive (4+)
Protein = positive (2+)
Identify the object in these photos

15. Case 12
This urine sample is from a 38 year old female history of three days nausea, vomiting and diarrhea. Laboratory data include:
Specific Gravity = 1.020
pH = 7.0
Leukocyte Esterase = negative
Glucose = negative
Protein = positive (1+)
Ketones = negative
Nitrite = negative
Blood = negative
Identify the object in these photo

16. Case 13
This urine sample is from a 14 year old female asymptomatic Laboratory data include:
Specific Gravity = 1.012
pH = 6.0
Leukocyte Esterase = negative
Glucose = negative
Protein = positive (1+)
Ketones = negative
Nitrite = negative
Blood = negative
Identify the object

17. Case 14
This urine sample is from a 62 year old male with enlarged prostate and renal failure. Has fever and dehydrated. Laboratory data include: BUN = 48 mg/dl (serum)
Creatinine = 3.4 mg/dl (serum)
Cloudy urine
pH = 6.6
Leukocyte Esterase = positive
Glucose = negative
Protein = positive
Ketones = negative
Nitrite = negative
Blood = negative
Identify the object

18. Case 15 This urine sample is from a 31 year old male routine exam.
Yellow and hazy urine
pH = 6.8
Leukocyte Esterase = negative
Glucose = negative
Protein = negative
Ketones = negative
Nitrite = negative
Blood = negative
Picture is regular light (left) and polarized light (right)
Identify the object

19. Case 16
This urine sample is from a 55 year old male with urinary tract infection.
Cloudy urine
Urine culture grows Proteus species
Identify the object

20. Case 17
This urine sample is from a 33 year old male with alcohol induced cirrhosis, ascites, and jaundice.
Golden brown urine in color
Specific gravity = 1.015
pH = 6.0
Identify the object

21. Case 18
This urine sample is from a 20 year old female with minimal change disease.
Golden brown urine in color
Specific gravity = 1.025
pH = 7.0
Protein = positive (4+)
Blood =negative
Leukocyte esterase = negative
Ketones = negative
Nitrite = negative
Identify the object

22. Case 19
This urine sample is from a 56 year old male with kidney and liver failure. Laboratory data include:
Specific Gravity = 1.012
pH = 5.0
Blood = positive
Protein = positive
Leukocyte esterase = positive
Glucose = negative
Ketones = negative
Nitrite = negative
Crystals soluble in HCL
Identify the object

23. Case 20
This urine sample is from a 45 year old female routine exam. Laboratory data included:
Specific gravity = 1.015
pH = 7.0
Blood = negative
Protein = trace
Leukocyte esterase = negative
Nitrite = negative
Glucose = negative
Ketones = negative
Identify the objects in photo

24. Case Study Results

25. Case 1 - Squamous Cell Large, flat, thin cells
May be round, polygonal, rectangular or rolled into a tube
Nucleus size of a RBC usually centrally located.
Can contain granules in cytoplasm.
Line urethra, bladder and vagina
Form protective barrier
Normal finding.
Increase number indicate not a clean voided specimen
If numerous the protein may be positive on the urine dipstick

26. Case 2 - Fiber Defined shapes Flat Refractile Frayed ends
Non-cylindrical shapes
These can be artifacts seen in urine. They may be confused with hyline cast.

27. Case 3 – Ammonium biurate
Neutral or alkaline pH
Yellow-brown
Spheres with radial or concentric striation
Irregular projections/thorns

28. Case 4 – Transitional epithelial cell
Spherical, ovoid, polyhedral
Smaller than epithelial, larger than renal
Increase with infection, post renal catheterization, urinary stones ``
These can be confused either with WBC or renal epithelial cells.

29. Case 5 – Cystine crystal Clear, colorless hexagonal plates(Stop signs)
Acidic urine <5.5
Birefringence absent
Abnormal crystal ``

30. Case 6 – Erythrocytes Round or oval biconcave disc No nucleus
Abnormal in increase numbers
Faint yellow-orange or red ``
Can be crenated in hypertonic urine and swell to “ghost” forms in hypotonic urine. The Hemoglobin should be positive on the dipstick

31. Case 7 – Calcium Oxalate
Usually in acidic but can be seen neutral or weakly alkaline
Colorless
Common shape envelop
Less common dumbbell, oval and elongated hexagon ``

32. Case 8 – RBC Cast Least common cast Most significant
Tinged red or brown
Seen in freshly voided specimens
Differentiated by presence intact RBC ``
Seen in acute glomerulonephritis, all glomerulopathies and malignant hypertension. The urine dipstick should be positive for hemoglobin

33. Case 9 – Leukocytes Colorless cells Most frequent is PMN
Normal 3-5 seen
Increased in inflammatory conditions
Most frequent is polymorphonuclear neutrophil of the WBC seen in urine. The leukocyte esterase should be positive on the dipstick

34. Case 10 – Waxy Cast High refractive index Blunt or broken off ends
Parallel margins may show notching
Colorless, pale yellow, waxy appearance
Abnormal finding
The protein should be positive on the dipstick.

35. Case 11 – Cholesterol Found in acid and neutral urine
Regular or irregular transparent plates
Birefringent in polarized light
Corner can be notched- stair step crystal
Abnormal finding

36. Case 12 – Yeast/fungi, extracellular
Usually ovoid and colorless
Refractile appearance
Can be branching or hyphae
Can be contaminant
Urinary tract infection if increase WBC seen
Can be confused with RBC

37. Case 13 – Uric Acid Crystals
Normal and common in urine
Acidic urine
Yellow or red-brown in color
Variety of forms- rhombic, rosettes, wedges, 4-sided plates, barrel, lemon shapes

38. Case 14 – Granular Cast Fine or coarse granules
Can be normal, especially after vigorous exercise
Seen in renal disease patients
Protein may be positive on the dipstick

39. Case 15 – Starch granule Colorless
Irregularly round with dark striation to the center
Asymmetric “Maltese cross” in polarized light. Can be confused with fat bodies.
Frequent contaminant
Note how the fate droplet “Maltese cross” is more symmetrical than the starch on the left
Starch polarized
Fat droplet
polarized

40. Case 16 – Triple Phosphate
Also know as Ammonium Magnesium Phosphate
Colorless
3-6 sided prism shaped
Resembles “coffin lid”
Less common as colorless sheets, flakes, flats, ferns or leaf form
Birefringent under polarized light
Seen highly alkaline urine with urea-splitting organisms mostly Proteus species.

41. Case 17 – Leucine Crystal Acidic urine
Spheroids with concentric striations
Dense
Highly refractile
Yellowish brown
“pseudo” Maltese cross
Seen severe liver disease
Hereditary amino acid metabolic disorders
Can be seen with tyrosine crystals

42. Case 18 – Fatty Cast Yellowish tinge
Contains large spherical, highly refractile fat droplets
Polarized light show “Maltese-cross” pattern
Associated with marked proteinuria and nephrotic syndrome
Protein may be positive on the dipstick

43. Case 19 – Tyrosine Crystals
Rare, always abnormal
Form clusters of silky needle-like structures
Colorless or black on focusing
Acid urine
Increase after refrigeration
Insoluble in alcohol or ether
Soluble in dilute HCL
Orange color with nitrosonaphthol confirmatory
Tyrosiuria occurs with liver disease

44. Case 20 – Hyaline Cast Colorless Transparent Low refractive index
Can easily missed with ordinary bright field light scope
Cylindrically shaped elements
Seen in healthy and also with renal disease
Small numbers usually
The protein may be positive on the dipstick

45. References Urinary Sediment: A Textbook Atlas, by Meryl H Haber
Images from
CAP Participant Summary for Clinical Microscopy